Section 6.3 Optimize
Optimization Strategies for Use of EHR and
HIE in Assessment, MDS, Care Plan, Visit,
and Teaching Documentation
Use this tool to help ensure that all assessment requirements, care plans, and clinician visits for your
clients can be efficiently and effectively documented. Optimization strategies for documentation
begin with proper configuration (i.e., system build), testing, and training. They extend to ensuring
adoption and optimal utilization.
Time needed: 4 hours
Suggested prior tools: Section 4.5 Workflow and Process Improvement with EHR and HIE, Section
4.7 Stewardship in HIE, Section 4.8 System Build, Section 4.16 Training Plan
How to Use
1. Determine that required assessments, care plans, and visits can be documented using your
electronic health record (EHR) system.
2. Use implementation tools in Section 4 to ensure optimal workflow and process design, data
management, system configuration, and training.
3. Use the workflow and process maps that have been redesigned to reflect your goals to verify
that users are using the EHR and HIE as intended by a specified time after go-live and on a
regular basis thereafter (see Section 5.3 Monitoring SMART Goal Achievement to Assure
Value from EHR and HIE).
Documenting the Patient Assessment
Most skilled nursing facilities find that documenting the patient assessment requires variable
workflows, depending on patient status, resource availability, and other factors. The EHR and HIE
capability you use should be able to accommodate a variety of functions:
 Referral portal or transaction. Receiving the referral should be enabled electronically. Ideally,
the facility uses a portal where those making the referral enter all pertinent data, or it would
come across via the Consolidated-Clinical Document Architecture (C-CDA) (see Section
2.12 Exchange of Clinical Summaries via CCR, CCD, C-CDA). At a minimum, the referral
functionality should include patient demographic and payment information, referral status
(e.g., under evaluation, admitted, on hold, ready), diagnosis, evidence of meeting
reimbursement requirements, and services required.
 Incorporating paper forms. It may be necessary to scan paper forms into the EHR. Some
paper forms come from external sources, such as hospitals, physician offices, etc. In addition,
some skilled nursing facilities may continue to provide some paper forms to patients or their
families/caregivers. These may include consent forms, agreements, and advance directives.
Prior to selecting your EHR and HIE, you should understand how many paper forms may
continue to be received after adoption and what electronic alternatives exist.
 Assessment completion guidance. A system that guides staff on what assessment information
is required and validates entries as accurate can significantly improve user satisfaction, speed
Section 6 Optimize—Optimization Strategies for Use of EHR and HIE in Assessment, MDS, Care Plan, Visit and Teaching - 1
assessment performance, eliminate errors and omissions, and reduce turnaround time for
orders and billing
Documenting Care Plans
Electronic plans of care can be achieved through most EHR systems. Many of these systems include
point of care (POC) templates specific to your patients’ problems. They should reflect all disciplines
treating the patient. Some EHR products enable you to create new templates or customize templates
to your standards of practice, physician expectations, or payer requirements. As care ensues,
clinicians can update the POC by adding, deleting, or modifying goals and interventions. When there
is a change in medications, visits, or other treatments, orders should be able to be generated from the
POC—in 485 or generic format as desired. These orders should then carry forward to the physician
dashboard for review and modification or approval.
Copyright © 2014
Updated 03-19-2014
Section 6 Optimize—Optimization Strategies for Use of EHR and HIE in Assessment, MDS, Care Plan, Visit and Teaching -2