Avatar User Guide: Adult/Older Adult Treatment Plan of Care/ Reassessment City and County of San Francisco

Transcription

1 Avatar User Guide: Adult/Older Adult Treatment Plan of Care/ Reassessment City and County of San Francisco Page 1 of 19

2 Adult/Older Adult Treatment Plan of Care/Reassessment The purpose of this manual is to walk you through the Adult/Older Adult Treatment Plan of Care/Reassessment screens in the Avatar Electronic Health Record system. This document serves to capture both the Plan of Care information as well as information necessary for the purposes of reassessment/justification for continued services. You will not need to complete a separate reassessment form. This form has been bundled with the Diagnosis Screen, which means that after you complete this form, the Diagnosis Screen will appear. This is necessary in order to meet MediCal standards of reassessment. This manual only covers how to enter this information into Avatar, for scoring, clinical policies about assessing clients, or frequency of plans of care, refer to your supervisor. You can search through the menus for this form, or just search for it by name. It s exact name is Adult/Older Adult Treatment Plan of Care/Reassessment Remember that you can search for part of it, and choose it from the menu that appears Searching for the Adult/Older Adult Treatment Plan of Care/Reassessment form Page 2 of 19

3 This is the first screen of the Treatment Plan of Care form. The grey bar at the top is the information of the client you re working with The first screen Page 3 of 19

4 Here s a closer look at the first page The top of the first page Enter everything in this first section, making sure to pay close attention to the Treatment Plan of Care Date and the Program. If you submit a treatment plan in draft, you can not change the date, even though you can change everything else about the treatment plan. Make sure it s correct before submitting Page 4 of 19

5 When choosing the status of the treatment plan, you ll notice that one option has been greyed out. If you require a cosign on your work, you can only put a treatment plan into Draft or Pending Approval. If you do not require a cosign on your work, you can only put a treatment plan into Draft or Final. If you require a cosign on your work, you will also have to enter the Team Member to Notify and the Team Member to Notify Outgoing Comments. This refers to the person who will be cosigning your work. Select your supervisor (or the person who cosigns your work) from the drop down menu. If you have any comments for the person reviewing your work, enter them into the Outgoing Comments field, otherwise write No Comments. Once you have completed this section, you can move on to the actual ANSA ratings Page 5 of 19

6 Enter a score for every single field. Every field is in red, even if it is not required (this allows you to save in draft without finishing the entire treatment plan.) If you need help with any section, hover over or click on the lightbulb for reminder text. If you need further help assigning a score, talk to your supervisor about the best clinical procedure. The beginning of the ANSA section At the bottom of the page are two buttons that launch separate reports. If you want to see a preview of how the completed plan of care will look, press the Treatment Plan of Care Preview button. This is not the complete report, and will not have the city seal or the client signature pages, so do not print this for your client to sign. The other will just have the ANSA ratings that you have entered. Page 6 of 19

7 Press these buttons to run preview reports Once you have finished entering the ANSA scores for your client, continue to the next two sections to complete the plan of care. If you re not finished with the ratings and want to come back to finish this plan at a later date, you can save in draft. Keep in mind that you cannot change the date after submitting, even in draft, so double check before submitting. When you re ready, continue to the next section of the treatment plan of care The sections of the Adult/Older Adult Treatment Plan of Care/Reassessment The next section is the Re-Assessment / Problem Statement / Justification. There is only one red required field, but talk to your supervisor about which fields are required at your agency. There is also has a button at the bottom that will launch a preview report. Page 7 of 19

8 The second section, Re-Assessment / Problem Statement / Justification The third and final section is the Short-Term Objectives / Interventions / PURQC Items. These are the objectives of the treatment plan, and are store in a multiple iteration table. First, click Add New Item. Page 8 of 19

9 After the new item as been added, you can enter the information by click or typing in the appropriate fields. The third and final section, Short-Term Objectives / Interventions / PURQC Items Page 9 of 19

10 After you have finished entering an objective, you can edit or delete information by selecting the row you want to change, then clicking the Edit Selected Item or Delete Selected Item button. For more information on entering data into these kinds of tables, see the video covering this subject. When you are finished, you screen should look something like the picture below An example of the Objectives section with an Objective / Intervention entered Page 10 of 19

11 Once you have finished entering the Objectives and you are ready to submit in Final (or Pending Approval), press the submit button. It will close, and automatically run the official Adult/Older Adult Treatment Plan of Care/Reassessment report, complete with the city seal and signature pages. A blank treatment plan of care report Page 11 of 19

12 You can then print this out and have your client sign it. Avatar will also automatically open the Diagnosis form. An updated diagnosis must be submitted on the same date with each treatment plan, even if the diagnosis has not changed. The Diagnosis form Page 12 of 19

13 This form will allow you to enter diagnosis information on the client. At the top, enter the kind of diagnosis. Choose Update as the Type of Diagnosis if there s already an Admission Diagnosis done. Otherwise, use Admission as the Type of Diagnosis. The Date Of Diagnosis must be the same date as the Plan of Care/Reassessment date. While you can enter and delete diagnoses at any time, there are a few things that s it s important to enter correctly. First among these is the order in which you enter your diagnoses. The primary diagnosis should be in the Diagnosis - Axis I - 1 field (or the Diagnosis - Axis II - 2 field, if the Axis II diagnosis is primary). The Axis I diagnosis fields Another requirement is that there must be an Axis II diagnosis, even if the diagnosis is deferred or there is no diagnosis. If there is no Axis II diagnosis for this client, enter V71.09 for No Diagnosis on Axis II or Condition on Axis I A third requirement is that cannot be the primary diagnosis. The Axis II diagnosis field. Page 13 of 19

14 The other required field in the Diagnosis form is the principal diagnosis drop down menu. Clicking on this will let you select from the diagnoses you have entered in order to choose the primary diagnosis for this client. This should be the diagnosis that you have entered into the Diagnosis - Axis I - 1 field, and cannot be The Principal Diagnosis drop down menu Once you have selected the principal diagnosis, the last required field is the diagnosing practitioner. There are a few rules that apply to this field as well. Talk to your supervisor about what can and cannot be entered into this field. If your agency uses Axis IV information or GAF scores, you can find those by scrolling down. Ask your supervisor if you have any questions about the use of these fields. If you need to enter a supplemental diagnosis, you can click on these sections to enter that information. Page 14 of 19

15 The Diagnosis form sections Otherwise, click Submit to save your changes. It will ask you if you want to return to Pre-Display The message you get when submitting a Diagnosis Click yes to see the diagnoses entered for this client. Page 15 of 19

16 The Diagnosis pre-display Page 16 of 19

17 From this pre display, you can see every diagnosis that has been entered for this client, sorted by date. There are a few things you can do from this screen. Take a look at the buttons at the bottom of the screen The Diagnosis form buttons, located at the bottom of the screen. Remember, you can add or remove a diagnosis at any time. If the diagnosis has been entered correctly, click Cancel to return to your home view. Once you see your home view, you have successfully completed the Adult/Older Adult Treatment Plan of Care/Reassessment and the associated Diagnosis Page 17 of 19

18 Printing the Treatment Plan of Care You can search through the menus for this form, or just search for it by name. It s exact name is Adult/Older Adult TPOC/Reassessment RPT Remember that you can search for part of it, and choose it from the menu that appears Searching for the report Once you have this form open, you are asked to select the client, episode, and the date for which the assessment was completed. Select all of these. Then, click Process. Page 18 of 19

19 The report will run and display the treatment plan of care report, complete with city seal and signature lines for the client to sign. A blank treatment plan of care report Page 19 of 19