Care Planning User Guide June PDF Free Download

Table of Contents Introduction... 1 About Care Plan... 1 About this Information... 1 Logon... 2 Care Planning Module Basics... 5 Starting Care Plan Editor... 5 Selecting a Resident... 6 Resident Information... 7 Care Plan Mast Window Anatomy... 8 Methods of Creating New Draft Care Plans... 11 Load from MDS... 11 Copy Previous Care Plan... 13 Enter Data... 16 Load from Problem Library... 18 Load from Health Condition Library... 21 Working with Care Plans... 25 Differentiating Among Statuses... 25 Entering Care Plan Information... 26 Creating New Problem Set Items... 28 Reordering Problem Set Items... 30 Discontinuing Problem Set Items... 32 Signing a Care Plan... 34 Appendix... 39 Entering Discharge Care Plan Information... 39 Managing Disciplines... 40 Notes History... 42 Re-Entering a Discontinued Item... 43 Reports... 46 Virtual Picture Chart... 48 2011, ADL Data Systems, Inc. All rights reserved iii

Introduction About Care Plan Care Plan empowers your clinicians to create flexible, comprehensive Care Plans from User Defined Libraries, each with a multitude of Problems, Goals, Approaches, and Assigned Disciplines. A Care Plan can be initiated from various sources, such as prior Care Plans, Libraries, or the most recent MDS. Care Planning uses our exclusive MDS Advanced Care Rules-Based Engine that evaluates responses to MDS & RAP triggers, and can create suggested Care Plans. Simply edit or add MDS Rules to customize and quickly develop a unique Library relevant to the needs in your facility. Problem Libraries provided with Care Plan were written in-house by Registered Nurses who understand the Care Plan process. With the Customizable Health Condition Library you can create bundles of symptoms to attach specific events or conditions - a time saving function to auto populate a Care Plan with just one click! About this Information This information provides you with instructions describing how to use ADL Data Systems Care Planning module. Instructions can be read while using the software or independently of it. Depending on certain criteria, some content or features will or will not be available. For example, if your security credentials prohibit you from viewing a particular section. This information assumes you have successfully logged on to the correct Facility and Unit with the appropriate User and Password credentials. Screen images will differ in your environment depending on the operating system and customized display settings. Sample data is shown. Moreover, it is sometimes the case that there will be more than one way to achieve the same result. For example, there is more than one way to locate a resident. The information contained herein does not necessarily provide instruction for every possible way. Boolean search expressions are permitted. Search results are not case sensitive. Wild card symbols and common words such as, but not limited to, "it" and "the" are ignored. Conduct your search for whole words only. For example, to locate the word "resident" it is better to input the entire string as opposed to "residen". ADL Data Systems takes pride in the quality of their documentation in addition to the quality control methods each Optimum EMR application undergoes. Do not hesitate to report any inaccuracies or discrepancies with this information. 05-23-11-1 2011, ADL Data Systems, Inc. All rights reserved 1

2. Click the ADL Optimum Clinicals button. 3. The Logon window displays. The By Facility button is selected by default. The remainder of this procedure assumes you wish to log in by facility. 4. Select the Facility from the Facility drop down list. 5. Select the Unit from the Unit drop down list or click the All Units check box to select every unit within the facility. 6. Select your user identification from the User drop down list. 7. Enter your Password in the corresponding window. 2011, ADL Data Systems, Inc. All rights reserved 3

Care Planning Module Basics Starting Care Plan Editor 1. Logon to Optimum EMR. 2. Select the EMR tab. 3. Open the Care Planning folder. 4. Click Care Plan Editor. The Care Plan Mast window displays. 2011, ADL Data Systems, Inc. All rights reserved 5

Selecting a Resident 1. Start Care Plan Editor. 2. Enter one or more characters of the resident's last name in the Search for edit window and press enter. If the entered last name is not unique or if you click the flashlight, the Account(s) Lookup window displays. 3. Input a value into one or more Search Criteria fields. Search results are further refined as data is input into more fields. 4. Click the Get button. If no rows are returned input different data. Click the Clear button to erase entries. 5. Alternatively, click the Get All button to return all residents in all units in the facility census. Scroll the results to locate the resident you wish to select. 6. Highlight (single click) the row and click OK. 7. The Care Plan Mast window populates with the residents allergy information. 8. You can repeat this procedure to select additional residents. 2011, ADL Data Systems, Inc. All rights reserved 6

Resident Information Basic resident information displays on each of the Care Plan main screens and includes Resident Name, Medical Record Number, Resident Identification number, RUGS score and ADL score. 1. Select the resident. 2. Observe the resident information bar. 3. If additional resident information is required, click the Info button to display the Resident Information window. 4. The MDS tab displays information about the selected resident s MDS history and the Dx Codes tab displays information about the selected resident s Diagnosis Codes. Resident information cannot be changed in the Care Plan module. 2011, ADL Data Systems, Inc. All rights reserved 7

Care Plan Mast Window Anatomy Account Selector Search for: Meaning / Description Used to lookup a resident by last name. Input a portion of the last name and click enter to display the Accounts(s) Lookup window. Displays the Accounts(s) Lookup window to select a different resident. Positions at the first resident in the group of selected residents. Positions at the resident in the selected group immediately preceding the current resident. Positions at the resident in the selected group immediately after the current resident. Positions at the last resident in the group of selected residents. Button Bar Meaning / Description Click to display the Reports window box. Click to display the MDS online help. Exits (closes) the Care Plan Mast window. Current Account Status Resident Name Medical Rec No. ID RUGS ADL Meaning / Description Resident's last name and first name. Resident medical record number. This number is unique to each resident and does not change. Resident's identification number, which changes for each new admission. The Federal RUGs score. ADL score. Opens the Resident Information window for a picture and additional basic demographic data. Action Buttons Meaning / Description Displays the Insert new Care Plan window, to begin creating a new Care Plan. You cannot create a Care Plan for a discharged resident or for a resident who already has a draft Care Plan created. Displays the Append to Care Plan window, to add information to the selected Care Plan. The same resources that were available when the Care Plan was initially created (Draft status) can be used. Deletes the selected Draft Care Plan grid row. You must respond Yes in the Confirm window to delete the record. Deleted Care Plans cannot be restored. 2011, ADL Data Systems, Inc. All rights reserved 8

Deactivates the selected Care Plan. You must respond Yes in the Confirm window to deactivate (change status to History) the record. Activates the selected Care Plan whose current status is Draft. Displays the Care Plan Entry window, to edit information for the selected Care Plan. Displays the Care Plan Entry window, to edit information for the selected Care Plan. Displays the Care Plan Entry window, to edit information for the selected Care Plan. Use for Resident Discharge Planning. Exits (closes) the Care Plan Mast window. In the Care Plan Mast window, multiple admissions (rows) for a particular resident can appear. The care plans display in chronological order and are grouped by admission date. Grid columns can be sorted. To sort (ascending or descending) a column click the column header. An upward or downward facing triangle appears in the column header to indicate which column the list is sorted by. Grid Reference date Meaning / Description Date the care plan is created. Indicates Draft, Active or History. Draft - The status when a Care Plan is initially created. Considered the developmental stage when all disciplines access the Care Plan and add their appropriate Problem Sets. Only one Draft Care Plan is permitted at any one time. The Create button is disabled until a New Care Plan is required, such as Annually or for a change of Status. Status Seq No Resident Family Source comment Active - The status a Draft Care Plan becomes after the Care Plan Team has met and agreed on the plan of care. Once Active, the Care Plan becomes "current" (on-going for the particular resident) and updated periodically as events occur. A Care Plan with this status remains in effect until a new Care Plan (Draft) is required, such as Annually or for a change of Status. Only one Active Care Plan is permitted at any one time. History - Indicates an "old" (no longer current) Care Plan. The status an Active Care Plan becomes when deactivated (DC button is used). More than one History Care Plan is permitted at one time. A consecutive number assigned by the system for ADL support use only. Select (check mark) the check box of each care plan grid row you want to indicate resident participation. Select (check mark) the check box of each care plan grid row you want to indicate family participation. Indicates the method used to create the care plan. 2011, ADL Data Systems, Inc. All rights reserved 9

Methods of Creating New Draft Care Plans Load from MDS Loading from MDS works in conjunction with MDS Rules. MDS Rules are guidelines set by the Facility to identify Problem Sets that are appropriately related to specific data in the MDS. The MDS must contain such data for this option to be used. For example, if the Rules have been set up by RAP Triggers only, then the most recent MDS must have RAPs triggered and completed. 1. Start the Care Plan Editor. 2. Select the resident you want to create a new Draft Care Plan for. 3. Select a date where there are currently no entries or entries other than Draft status. 4. Click Create. The Insert new Care Plan window displays. 5. Select the Load from Last Error Free MDS radio button. 2011, ADL Data Systems, Inc. All rights reserved 11

6. Click Next. 7. Select (check mark) the check box of the problem statement, goal statement, approach and/or discipline to include in the residents Care Plan. Selecting a problem statement selects all goal statements beneath it. Selecting a goal statement selects all approaches beneath it. Selecting an approach selects all disciplines beneath it. For this reason it is recommended that you make selections starting from the lowest level to avoid including unwanted items in the Care Plan. 8. Click Finish. Click to display selected items only. Click to select all items. Click to deselect all items. Click to expand all items. Click to collapse all items. 2011, ADL Data Systems, Inc. All rights reserved 12

Copy Previous Care Plan Copying from a previous Care Plan allows you to view the contents of an existing Care Plan and choose which Problem Sets to continue with in the new Care Plan. 1. Start the Care Plan Editor. 2. Select the resident you want to create a new Draft Care Plan for. 3. Select a date where there are currently no entries or entries other than Draft status. 4. Click Create. The Insert new Care Plan window displays. 5. Select the Copy from Previous Care Plan radio button. 2011, ADL Data Systems, Inc. All rights reserved 13

8. Click Next. 9. Select (check mark) the check box of the problem statement, goal statement, approach and/or discipline to include in the residents Care Plan. Selecting a problem statement selects all goal statements beneath it. Selecting a goal statement selects all approaches beneath it. Selecting an approach selects all disciplines beneath it. For this reason it is recommended that you make selections starting from the lowest level to avoid including unwanted items in the Care Plan. 10. Click Finish. Click to display selected items only. Click to select all items. Click to deselect all items. Click to expand all items. Click to collapse all items. 2011, ADL Data Systems, Inc. All rights reserved 15

Enter Data Entering data allows you to create customized (in your own words) Problem Sets. 1. Start the Care Plan Editor. 2. Select the resident you want to create a new Draft Care Plan for. 3. Select a date where there are currently no entries or entries other than Draft status. 4. Click Create. The Insert new Care Plan window displays. 5. Select the Enter using data entry screens radio button. 2011, ADL Data Systems, Inc. All rights reserved 16

6. Click Next. 7. Select a Reference Date using the calendar control. 8. Select the Resident Involved check box if you want to indicate resident participation. 9. Select the Family Involved check box if you want to indicate family participation. 10. Click Finish. 2011, ADL Data Systems, Inc. All rights reserved 17

Load from Problem Library Loading from the Problem Library allows you to select any Problem Set available to the Facility. Facilities can periodically improve and expand their Library. 1. Start the Care Plan Editor. 2. Select the resident you want to create a new Draft Care Plan for. 3. Select a date where there are currently no entries or entries other than Draft status. 4. Click Create. The Insert new Care Plan window displays. 5. Select the Load from Problem Library radio button. 2011, ADL Data Systems, Inc. All rights reserved 18

6. Click Next. 7. Use the Search drop down list to select a field. 8. Input the for a value of string in the corresponding edit window. Depending on the selected Search field, an ellipse can appear in this edit window. Clicking the ellipse displays a lookup window with values specific to the field you have chosen. You can make a selection from the lookup window or click inside the edit window and type directly into it. 9. Click the load problems based on search criteria button. The screen displays Problem Sets that match your search criteria. For example, as shown in the following image, problems related to "pain" were searched. 2011, ADL Data Systems, Inc. All rights reserved 19

10. If necessary, repeat steps 7, 8 and 9 to populate the screen with additional Problem Sets. 11. Select (check mark) the check box of the problem statement, goal statement, approach and/or discipline to include in the residents Care Plan. Selecting a problem statement selects all goal statements beneath it. Selecting a goal statement selects all approaches beneath it. Selecting an approach selects all disciplines beneath it. For this reason it is recommended that you make selections starting from the lowest level to avoid including unwanted items in the Care Plan. 12. Click Finish. Click to display selected items only. Click to select all items. Click to deselect all items. Click to expand all items. Click to collapse all items. 2011, ADL Data Systems, Inc. All rights reserved 20

Load from Health Condition Library Loading from the Health Condition Library allows you to add several appropriate Problem Sets at one time. Conditions like Diabetes or Alzheimer s are identified and multiple Problem Sets are attached. 1. Start the Care Plan Editor. 2. Select the resident you want to create a new Draft Care Plan for. 3. Select a date where there are currently no entries or entries other than Draft status. 4. Click Create. The Insert new Care Plan window displays. 5. Select the Load from Health Condition Library radio button. 2011, ADL Data Systems, Inc. All rights reserved 21

6. Click Next. 7. Specify (input) the Choose a Health Condition string. Clicking the ellipse displays the Health Condition Lookup window. You can make a selection from the lookup window or click inside the edit window and type directly into it. 8. Click the load problems linked with health condition button. The screen displays Problem Sets that match your search criteria. For example, as shown in the following image, problems related to "Parkinson's Disease" were searched. 2011, ADL Data Systems, Inc. All rights reserved 22

9. If necessary, repeat steps 7 and 8 to populate the screen with additional Problem Sets. 10. Select (check mark) the check box of the problem statement, goal statement, approach and/or discipline to include in the residents Care Plan. Selecting a problem statement selects all goal statements beneath it. Selecting a goal statement selects all approaches beneath it. Selecting an approach selects all disciplines beneath it. For this reason it is recommended that you make selections starting from the lowest level to avoid including unwanted items in the Care Plan. 11. Click Finish. Click to display selected items only. Click to select all items. Click to deselect all items. Click to expand all items. Click to collapse all items. 2011, ADL Data Systems, Inc. All rights reserved 23

Working with Care Plans Differentiating Among Statuses When a Care Plan is initially created, its status is "Draft". A Care Plan whose status is draft is essentially "under development" and is a time during which team participants enter and edit Problem Sets (Care Plan information) for the resident. A Draft Care Plan is not part of the legal medical record. Because it is not part of the legal medical record, a Care Plan whose status is Draft can be deleted. When team participants are satisfied that the Draft Care Plan meets the required medical needs of the Resident, the Care Plan is activated. An Active Care Plan is part of the legal medical record. As the Resident s condition changes, Goals are reached, Approaches may no longer be appropriate, new Approaches may be tried, and Problems may be completely resolved. To accommodate this, the Active Care Plan can be deactivated and a new Care Plan created and subsequently activated. The system allows items to be both deactivated and then re-entered at a later date if needed to accommodate clinical changes. When deactivated, the Status is changed to "History". A Care Plan whose status is Active cannot be deleted. 2011, ADL Data Systems, Inc. All rights reserved 25

Entering Care Plan Information 1. Select the Care Plan of the Resident you want to enter Problem Set information. 2. Click the CP button. The Care Plan Entry window displays. 3. Select an individual Problem Set line item. 4. Enter information in the appropriate fields in the lower half of the window. 5. Click Save. 6. Review and enter information for each Problem Set line item, proceeding consecutively through the Problem Set. That is, edit the problem statement, followed by editing all goals of that problem statement, followed by editing all approaches of each goal and lastly followed by editing all disciplines of each approach. 2011, ADL Data Systems, Inc. All rights reserved 26

You may need to click the splitter bar toward the bottom center of the window, click a blank area adjacent to a Problem Set or double-click a Problem Set to display the fields. The bottom portion of the window (fields) change depending on whether you have selected a problem statement, goal, approach or discipline. You need to enter information for each item in the Problem Set. The Author Discipline field is meant to refer to the person who wrote the item originally, however, this may be changed by the current user. Typically, this would not be changed unless significant changes are made. 2011, ADL Data Systems, Inc. All rights reserved 27

Creating New Problem Set Items 1. Access the Care Plan Entry window. 2. Select the item that immediately precedes or is at the same level the item you want to create. For example, if you want to add a goal to a problem statement, select the problem statement that you want the goal to belong too. If you want to add an approach, select the goal that the approach will belong too. If you want to add a discipline, select the approach that the discipline will belong too. If you want to add a problem statement, select an existing problem statement. 3. Click Insert. The Create new CP entry window displays. 4. Select the radio button that corresponds to the Problem Set item you want to create. 5. Click Next. 2011, ADL Data Systems, Inc. All rights reserved 28

6. Choose a method by which this Problem Set item will be created by selecting the appropriate radio button. 7. Click Next. 8. Specify one or more Problem Set items to create. 9. Click Finish. More than one Discipline can be added to the same Approach. More than one Approach can be added to the same Goal. More than one Goal can be added to the same Problem Statement. 2011, ADL Data Systems, Inc. All rights reserved 29

Reordering Problem Set Items 1. Access the Care Plan Entry window. 2. Click the Reorder Care Plan button. The CP Reorder window displays. 3. Click (left) and hold a Problem Set item. 4. "Drag" upward to the desired location. 2011, ADL Data Systems, Inc. All rights reserved 30

5. Release the mouse button. 6. Continue moving Problem Set items as required. 7. Click Save. Problem Set items initially display in the Care Plan in the order in which they were added. Problem Set items can be moved in an upward direction only. Using the previous images as an example, you can see that "Resident's area around tracheostomy tube will be free of excoriation within 90 days" has been moved. 2011, ADL Data Systems, Inc. All rights reserved 31

Discontinuing Problem Set Items 1. Access the Care Plan Entry window of a Care Plan whose status is Active. 2. Select the discipline, approach, goal or problem statement you want to discontinue. For example, as shown in the following image, the clinician wants to discontinue the "Maintain clean, dry skin" approach. 3. Click D/C. The Discontinue <Problem Statement Item> window displays. 4. Select a Resolution status and DC date. 2011, ADL Data Systems, Inc. All rights reserved 32

5. Click Finish. The Problem Set item icon changes to grey, indicating it has been discontinued. When an item is discontinued, any items subordinate to that item are also discontinued. 2011, ADL Data Systems, Inc. All rights reserved 33

Signing a Care Plan Each participating clinician can enter their name as indication of their part in developing and maintaining a Resident s Care Plan. 1. Access the Care Plan Entry window. 2. Click the Sign-Off tab. 2011, ADL Data Systems, Inc. All rights reserved 34

4. The Signature / User ID field must be populated by selecting a value from the Lookup window. This is to say that you cannot type directly into this field. Click the ellipse to display the Lookup window. 5. Locate and select the correct Description (code, user name, role). 6. Click OK. 7. Enter the correct Password. Entered characters appear as an asterisk (*). 2011, ADL Data Systems, Inc. All rights reserved 36

8. The Discipline field must be populated by selecting a value from the Lookup window. This is to say that you cannot type directly into this field. Click the ellipse to display the Lookup window. 9. Locate and select the correct Description (code, role). 10. Click OK. 11. Click Save. 2011, ADL Data Systems, Inc. All rights reserved 37

Appendix Entering Discharge Care Plan Information 1. Select the Active Care Plan of the Resident you want to enter discharge Care Plan information for. 2. Click the Dischrg button. The Care Plan Entry window displays. 3. Enter information in the appropriate fields. 4. Click Save. 2011, ADL Data Systems, Inc. All rights reserved 39

Managing Disciplines 1. Access the Care Plan Entry window. 2. Right mouse click on an Approach or Discipline line item. 3. Select Add new Discipline. The Discipline Lookup window displays. 4. To insert a new Discipline, click Insert. The Add Discipline window displays. 5. Enter a Discipline Code. 6. You have the option of entering a Description and/or Map to CODE. 7. Click OK. 2011, ADL Data Systems, Inc. All rights reserved 40

More than one Discipline can be added to the same Approach. To edit a Discipline select the Discipline CODE, click Edit, make modifications in the Add Discipline window and click OK. To disable a Discipline select the Discipline CODE you want to disable and click the Disable button. To enable a Discipline select the Discipline CODE you want to enable and click the Enable button. 2011, ADL Data Systems, Inc. All rights reserved 41

Notes History 1. Select the Care Plan of the Resident you want to enter Notes History for. 2. Access the Care Plan Entry window. 3. Click the Notes button. The Notes History Mast window displays. Refer to Notes History documentation if required. 2011, ADL Data Systems, Inc. All rights reserved 42

Re-Entering a Discontinued Item 1. Access the Care Plan Entry window. 2. Locate the discontinued item you want to re-enter. Discontinued item icons appear grey. 3. Select the discipline, approach, goal or problem statement that is discontinued. For example, as shown in the following image, the clinician wants to re-enter the "Maintain clean, dry skin" approach. 2011, ADL Data Systems, Inc. All rights reserved 43

5. Select Re-Enter from the pop-up menu. As shown in the following image, the reentered item is appended to the list. The original discontinue item remains. When an item is re-entered, any items subordinate to that item are also re-entered. When re-entering a problem statement item, the Enter new Problem Code window prompts you to input a New Problem Code. 2011, ADL Data Systems, Inc. All rights reserved 45

Reports There are many types of Care Plan reports available. Reports can be viewed and/or printed. 1. Start the Care Plan Editor. 2. Select the resident you want to view or print a Care Plan report for. 3. Click the Reports button. The Reports window displays. 4. Use the Select report drop down list to choose a specific report. 5. Depending on the report you choose, other fields in this window can be enabled. If a field is enabled, you can use the particular field control to filter the report content. 2011, ADL Data Systems, Inc. All rights reserved 46

6. Click OK. The report displays in the Preview window. You can view, print or perform other operations using the controls in this window. If the Discipline field is blank a separate report is generated for each discipline. The Clear button can be used to remove a selected Discipline. The Start and/or End dates do not need to be specified (i.e. can be blank). The Reports button is available on other (in addition to the Care Plan Mast) windows within the Care Plan Module. 2011, ADL Data Systems, Inc. All rights reserved 47

Virtual Picture Chart 1. Select the Care Plan of the Resident you want to view the virtual picture chart of. 2. Access the Care Plan Entry window. 3. Click the Virtual Picture Chart button. 4. Select Virtual Body, Virtual Feet or Virtual Head, depending on what you want to view. The following image sample is that of Virtual Head. Refer to Virtual Body documentation if required. 2011, ADL Data Systems, Inc. All rights reserved 48

Care Planning User Guide June 2011