POINT CARE
DECEMBER 9, 2009 UPGRADE
1. UNEXPECT ED EVENTS
1. The Unexpected Event feature is available when you first start the visit.
2. An Unexpected Event is a situation where the original reason for the visit
changes and such change requires a change in the type of physical assessment
form to one which includes one of the OASIS data sets [i.e., Transfer to Inpatient
Facility, Resumption of Care, Follow-Up “SCIC” etc.].
3. Unexpected Events apply to the following disciplines: RN, PT, OT and ST only.
4. If an unexpected event occurs in the middle of a visit you are documenting in,
and you answered the initial unexpected event “NO”, you must RESTART the
visit.
See instructions on the next page for “how to turn a revisit into a follow-up visit”.
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HOW TO USE POINT-CARE “UNEXPECTED EVENT” TO TURN A REVISIT
INTO A FOLLOW-UP (SCIC) VISIT
In the event your patient’s status changes, you will need to trigger an “unexpected event”,
so you can complete a follow-up visit, in order to revise the original plan of care, based
upon the additional needs of the patient.
For example, on admission you may have selected a cardiac and a respiratory NDP for
your patient. Upon a revisit, you learn that the patient was newly diagnosed with
diabetes. In order for the plan of care to reflect the diabetes, a follow-up assessment must
be done, as this is truly a “significant change in condition”.
Completing the follow-up is the ONLY way to add the new diagnosis code, and to add
the appropriate NDP, which will cause the diabetes specific interventions, intervention
details and goals to carry over to all future subsequent visits.
Remember, you will need to restart your revisit in order to trigger the unexpected event,
so be sure to ask your patient upon arrival in his/her home: “Has anything changed since
you were last visited by a nurse or therapist”? This will prevent you from completing
anything in the revisit that would have to be re-done in the follow-up visit, as anytime a
visit is ‘restarted” it erases any data you have already entered.
INSTRUCT IONS:
1. tap ACTION (lower left side of screen)
2. tap RESTART VISIT (tap “yes” to “are you sure you want to restart this visit”
message)
3. SYNCH
4. Locate the SAME revisit on your Point-Care calendar
5. Start the revisit again
6. When “unexpected events” screen comes up, select FOLLOW-UP – your visit
will now automatically change to a FOLLOW-UP/SCIC visit
IMPORTANT REMINDER:
The same process may be followed to turn a revisit into a TIF – in the event you need to
complete a “transfer to inpatient facility” assessment, you can do so in the field,
eliminating the need to call the office to schedule a TIF to you. Be sure to include a
“transfer to inpatient facility” physician verbal order.
UNEXPECTED EVENT FUNCTIONALITY IS NECESSARY TO COMPLY
WITH THE NEW MANDATORY FALL PREVENTION PROCESS (next page)
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FALL PREVENTION PROCESS
Mandatory for all disciplines - effective 1/1/09
ADMISSIONS:
1. V-Code V15.88 is to be added to referral by HCIC/Intake whenever possible,
based upon referral summary Q&A.
2. Upon start of care, admitting clinician is to complete fall risk tool – a score of
4 or more indicates a risk to fall – clinician will go to Diagnoses and add
V15.88 immediately, then go on with the rest of the assessment.
a. The new “fall prevention” form will be the first category under the
physical assessment list. Be sure to complete this early in your visit to
avoid having to re-document – if the patient had a change in fall risk
status, a follow up “SCIC” will need to be completed. (see below)
3. If admitting clinician does NOT add V-code appropriately, Clinical Manager
needs to add V15.88 to diagnoses AND “all Prevention” NDP prior to
approving SOC documentation.
IF FALL RISK STATUS CHANGES ON REVISIT:
1. Upon arrival in patient’s home, ask if anything has changed since last visit –
for “YES” response, immediately re-assess fall risk status in physical
assessment.
2. If score = 4 or more, “restart” visit immediately, and synch (follow
unexpected event instructions provided in 12/9/09 Point Care upgrade
documentation on page 1).
3. Start your revisit, the first screen to open will be “unexpected event”. Select
“follow-up”, then complete “SCIC” visit as appropriate, by adding V15.88 to
diagnosis list, which will trigger the addition of the “fall prevention” NDP.
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2. WORKER DASHBOARD
If an agency has elected to check the appropriate system setting, a Worker Dashboard
screen will be displayed after initial login into Point Care and will be available from the
action menu on the rolling calendar screen.
·
To access the Worker Dashboard, click on
Action from the rolling calendar screen and
then click on Worker Dashboard.
·
The dashboard contains three sections:
ü Worker Key Metrics – Displays view
only data about visits previously
completed by the worker. Several key
metrics are shown on this screen but
user can tap the View All link to see the
full Worker Metrics.
ü Visits – The Visits section displays an
icon for each visit status that currently
exists in PointCare, along with the
number of visits with that status. For the
example shown below, two Accepted
visits and one visit for each status of
Pending, Late and Missed are currently
in PointCare.
·
(a) A maximum of six different statuses
will show. If there are more than six
statuses with visit counts greater
4
than zero, a ‘more…’ link will be
shown.
(b) Tapping the VISITS link navigates to
the existing patient visits screen.
(c) Tapping the
(Late) icon
navigates to the Open tab where
Late visits reside.
(d) Tapping on the other icons navigates
to the Open tab if there is at least
one visit that is not the current day;
otherwise it navigates to ‘today’.
Worker Messages – Disabled for now but will
ultimately allow user to access worker
communication notes - similar to client coordination
notes.
·
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Tapping the View All link in the Worker Key
Metrics section displays an additional screen
that shows all worker metrics
·
Worker Key Metrics displays Productivity and
Visit Detail information.
DATA DEFINITIONS
1. Timeframes
A. Current Week – The current Sunday through Saturday relative to the current date
B. Prior Week – The prior Sunday through Saturday relative to the current date
C. Prior 4 Weeks (Avg) – Average of the prior 4 Sunday through Saturdays relative to the current
date (excluding Current Week)
D. Prior 0-30 Days – The last 30 days relative to the current date
E. Prior 31-60 Days – The last 31-60 days relative to the current date
F. Prior 61-90 Days – The last 61-90 days relative to the current date
2. Productivity
A. Points Completed – Total of all productivity points where visit has been completed and
synched + productivity points associated with approved NVT.
B. Points Scheduled – Worker’s total scheduled productivity points minus Points Completed +
productivity points associated with approved NVT.
C. Total Points – Total number of Points Completed + Points Scheduled
D. Points Over/Under Productivity – Total Points Completed minus worker’s Expected Points. If
the worker is below or above their productivity, +/- signs will be shown and color coded (green
for positive number; red for negative number). If the value is 0 (worker is right at productivity),
it will be shown in black. This row will be hidden if the expected number of productivity points
has not been setup for the worker.
E. Total Hours Worked – Total time worked (visit total time + approved NVT).
1) Current and Prior Week – Sum of total visit time [in-home + additional] of processed visits
+ total approved NVT + total Drive Time.
2) Prior 4 Weeks (Avg) – Average of total visit time of processed visits + total approved NVT
+ total Drive Time.
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3. Visit Details
A. Avg In-Home Time – Average In-Home Time (from Begin event to first Incomplete event) of all
processed visits (in minutes)
B. Avg Add’l Doc Time - Average additional time (from first Incomplete event to Complete event)
of all processed visits (in minutes)
C. Avg Drive Time – Average drive/travel time of all processed visits (in minutes)
D. Avg Total Time – Average total time (from Begin event to Complete event) of all processed
visits (in minutes)
E. Avg Total Time per Prod Point – Total Visit Time divided by Total Productivity Points for
completed visits.
F. Avg % of Doc Completed Same Day - Number of visits where documentation was completed
in home + number of visits where documentation was completed in PointCare on the same day
as the visit / number of total visits completed in that period.
G. % Visits Completed in Home – Number of visits where the first time event=Complete or
Incomplete divided by the total number of visits. This includes ‘Late’ visits.
H. % Doc Completed in Home – Total In-Home Time divided by Total In-Home Time +
Documentation Time
I. Avg Time to Sync Visits – Average insert date/time processed into HCHB minus the date/time
of the first stop event (Incompleted or Completed) (in minutes)
J. Note: Medical Treatment and Hospice Medical Treatment visit types are excluded
K. All times are displayed in format like 1:25 (for 1 hour and 25 minutes); 37 minutes will show as
0:37.
4. Episode Statistics – Only data for Medicare patients will display due to the reliance on OASIS,
among other things to determine standard vs. therapy episodes. The statistics in this section will
only be for those episodes started by this worker (the worker was the evaluating caregiver on the
SOC or Recert visit).
A. Average SOE Case Mix – Average Case Mix value where SOE Date started during the
timeframe for all episodes regardless of reimbursement basis.
B. Percent of SOEs-Standard – Percent of episodes where SOE Date started within the
timeframe and episode reimbursement basis=Standard. Standard Episodes divided by Total
Episodes gives this statistic.
C. Percent of SOEs-Therapy – Percent of episodes where SOE Date started within the timeframe
and episode reimbursement basis=Therapy. Therapy Episodes divided by Total Episodes
gives this statistic.
D. Avg Visits Per Std Epi-SN – Average SN visit count (plotted + requested + scheduled + verified
billable visits) where episode category=Standard.
E. Avg Visits Per Std Epi-HHA – Average HHA visit count (plotted + requested + scheduled +
verified billable visits) where episode category=Standard.
F. Avg Visits Per Std Epi – Other – Average visit count (plotted + requested + scheduled +
verified billable visits) that does not equal SN or HHA where episode category=Standard.
G. Avg Visits Per Std Epi – Total – Average visit count for all visits (plotted + requested +
scheduled + verified billable visits) where episode category=Standard.
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3. Outcomes
If setting is enabled in the Clinical Manager, the Outcome Measures Report will
automatically display upon tapping the OK button to exit the physical assessment
section during Discharge and Transfer to Inpatient Facility visit types.
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·
The report will show only after an asterisk is
present for all categories. (In other words, the
report will not show if some questions have not
been answered.)
·
The report will display if user re-accesses
Physical Assessment and taps OK to exit
again.
·
Grouped by Outcome Category [i.e., Activities
of Daily Living]
·
Each measure for the category is shown [i.e.,
Improvement in Bathing]
·
The OASIS M0 number (or numbers) used for
the measure is displayed as well.
·
A comparison of the answers between the two
time points (i.e., at SOC and DC) is shown.
·
Outcomes compare the answer at DC or TIF
to the answer at SOC or most recent ROC.
·
Whether or not a positive outcome was
achieved is shown. Yes, No, or N/A will
indicate the outcome result. Positive outcomes
(Yes) will show in green; negative outcomes
(No) will show in red.
·
If a measure uses more than one OASIS
answer [i.e., Acute Care Hospitalization], each
M0 question is shown.
·
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Tap any of the rows to view the full question
and answers given in each OASIS
assessment.
4. INTEGUMENTARY COMMAND CENTER
The Integumentary Command Center is a new layer within the physical assessment
section. When an assessment item category is accessed that has the ‘Integumentary
Category’ flag set to Y in the Clinical Manager, the ICC will display when the category is
accessed.
A. If the category contains the ICC, it is shown in red on the main Physical
Assessment screen as an identifier.
B. As a side note: The layout of the main screen for Physical Assessment,
Interventions, and Goals has been modified to be more user friendly. The ‘Open
Form’ button has been removed. Simply tapping the category opens the form.
C. If the ICC exists as part of the category, user has the option to go into the ICC or
open the assessment form directly.
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The ICC contains various hyperlinks to other features and/or references in PointCare
that may be related to care of the skin.
D. If an item is accessed and completed within the ICC, an asterisk will be displayed
on the main quadrant screen as well. For example, if the Interventions are
completed here, an asterisk will be inserted next to the Interventions sections in
the pink quadrant.
E. Items that are not part of the PointCare format or applicable to the client will not
show. For example, if Supply Requisitions and Supplies Del/Used are not
normally shown in the pink quadrant for the visit format, they won’t appear here
either. If an active Physician Protocol is not present, this section will not be
shown.
F. The only required item within the ICC is the actual assessment form.
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G. Features – Anatomical Image: This feature will be enhanced at a future date. The
ultimate goal for this is to allow user to select an image, tap on a body part,
document details of the skin alteration, and to insert a pinpoint of the skin
alteration.
H. Reference/PRN Section – Again, accessing these links will simply take you to the
existing feature in PointCare. Note about Wound Care Orders – Will display all
orders that have the ‘wound care order’ flag set to Yes.
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PLEASE NOTE:
The “weekly wound measurement” coordination note will NOT be available for use
after the upgrade on 12/9/09.
All nursing staff MUST use the wound sheet on wound measurement days
(located under the word “wounds” in the lower left quadrant in Point Care).
The process will NOT change. Wounds will still be measured once a week and the
wound sheet should be used on measurement visits.
On non-measurement days, nurses will document wound information in physical
assessment, under the “integument” category.
In order to use the “Integument Command Center” feature, the wound sheet must
be used so information flows between orders, physical assessment, supplies and
the wound sheet.
WOUND LOOKUPS
Field
DEPTH
Score
1
2
3
4
5
EDGES
1
2
3
4
5
EPITHELIALIZATION
1
NON-BLANCHABLE ERYTHEMA ON INTACT SKIN
PARTIAL-THICKNESS SKIN LOSS INVOLVING EPIDERMIS &/OR
DERMIS
FULL THICKNESS SKIN LOSS INVOLVING DAMAGE OR NECROSIS
OF SQ TISSUE; MAY EXTEND DOWN TO BUT NOT THROUGH
UNDERLYING FASCIA; &/OR MIXED PARTIAL OR FULL-THICKNESS
&/OR TISSUE LAYERS OBSCURED BY GRANULATION TISSUE
OBSCURED BY NECROSIS
FULL-THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION
TISSUE NECROSIS OR DAMAGE TO MUSCLE, BONE OR
SUPPORTING STRUCTURES
INDISTINCT, DIFFUSE, NONE CLEARLY VISIBLE
DISTINCT, OUTLINE CLEARLY VISIBLE, ATTACHED, EVEN WITH
WOUND BASE
WELL DEFINED, NOT ATTACHED TO WOUND BASE
WELL DEFINED, NOT ATTACHED TO BASE, ROLLED UNDER,
THICKENED
WELL DEFINED, FIBROTIC, SCARRED OR HYPERKERATOTIC
3
4
5
100% OF WOUND COVERED, SURFACE INTACT
75% TO < 100% OF WOUND COVERED &/OR EPITHELIAL TISSUE
EXTENDS > 0.5 CM INTO WOUND BED
50% TO < 75% OF WOUND COVERED &/OR EPITHELIAL TISSUE
EXTENDS < 0.5 CM INTO WOUND BED
25% TO < 50% OF WOUND COVERED
< 25% OF WOUND COVERED
1
2
NONE
SCANT
2
EXUDATE AMT
Description
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EXUDATE TYPE
3
4
5
SMALL
MODERATE
LARGE
1
2
3
4
NONE
BLOODY
SEROSANGUINEOUS: THIN, WATERY, PALE RED/PINK
SEROUS: THIN, WATERY, CLEAR
PURULENT: THIN OR THICK, OPAQUE, TAN/YELLOW WITH OR
WITHOUT ODOR
5
GRANULATION
TISSUE
NECROTIC TISSUE
AMOUNT
NECROTIC TISSUE
TYPE
1
2
3
4
5
SKIN INTACT OR PARTIAL THICKNESS WOUND
BRIGHT, BEEFY RED; 75% TO 100% OF WOUND FILLED &/OR
TISSUE OVERGROWTH
BRIGHT, BEEFY RED; < 75% & > 25% OF WOUND FILLED
PINK, &/OR DULL, DUSKY RED &/OR FILLS <= 25% OF WOUND
NO GRANULATION TISSUE PRESENT
1
2
3
4
5
NONE VISIBLE
< 25% OF WOUND BED COVERED
25% TO 50% OF WOUND COVERED
> 50% AND < 75% OF WOUND COVERED
75% TO 100% OF WOUND COVERED
1
NONE VISIBLE
WHITE/GRAY NON-VISIBLE TISSUE OR NON-ADHERENT YELLOW
SLOUGH
LOOSELY ADHERENT YELLOW SLOUGH
ADHERENT, SOFT BLACK ESCHAR
FIRMLY ADHERENT, HARD BLACK ESCHAR
2
3
4
5
PERIPHERAL
TISSUE EDEMA
PERIPHERAL
TISSUE
INDURATION
SKIN COLOR
SURROUNDING
WOUND
1
2
3
4
5
NO SWELLING OR EDEMA
NON-PITTING EDEMA EXTENDS < 4 CM AROUND WOUND
NON-PITTING EDEMA EXTENDS >= 4 CM AROUND WOUND
PITTING EDEMA EXTENDS < 4 CM AROUND WOUND
CREPITUS AND/OR PITTING EDEMA EXTENDS >= 4 CM AROUND
WOUND
1
2
3
4
5
NONE PRESENT
INDURATION < 2 CM AROUND WOUND
INDURATION 2 TO 4 CM EXTENDING < 50% AROUND WOUND
INDURATION 2 TO 4 CM EXTENDING >= 50% AROUND WOUND
INDURATION > 4 CM IN ANY AREA AROUND WOUND
1
PINK OR NORMAL FOR ETHNIC GROUP
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WOUND
2
3
4
5
BRIGHT RED &/OR BLANCHES TO TOUCH
WHITE OR GRAY PALLOR OR HYPOPIGMENTED
DARK RED OR PURPLE &/OR NON-BLANCHABLE
BLACK OR HYPERPIGMENTED
UNDERMINING
1
2
3
4
5
NONE PRESENT
UNDERMINING < 2 CM IN ANY AREA
UNDERMINING 2 TO 4 CM INVOLVING < 50% WOUND MARGINS
UNDERMINING 2 TO 4 CM INVOLVING > 50% WOUND MARGINS
UNDERMINING > 4 CM OR TUNNELING IN ANY AREA
WOUND BED
1
5
NON-BLANCHABLE ERYTHEMA ON INTACT SKIN
PARTIAL-THICKNESS SKIN LOSS INVOLVING EPIDERMIS &/OR
DERMIS
FULL THICKNESS SKIN LOSS INVOLVING DAMAGE OR NECROSIS
OF SQ TISSUE; MAY EXTEND DOWN TO BUT NOT THROUGH
UNDERLYING FASCIA; &/OR MIXED PARTIAL OR FULL-THICKNESS
&/OR TISSUE LAYERS OBSCURED BY GRANULATION TISSUE
OBSCURED BY NECROSIS
FULL-THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION
TISSUE NECROSIS OR DAMAGE TO MUSCLE, BONE OR
SUPPORTING STRUCTURES
WOUND STAGE
1
2
3
4
5
STAGE 1
STAGE 2
STAGE 3
STAGE 4
UNABLE TO STAGE
WOUND TYPE
1
2
3
4
5
6
7
8
9
PRESSURE ULCER
ARTERIAL ULCER
STASIS ULCER
DIABETIC ULCER
BURN
SKIN TEAR
ABRASION
SURGICAL INCISION
OTHER (SPECIFY)
2
3
4
WOUND LOCATION
Active
Y
Y
Y
Y
Y
Y
Y
Required
Y
Y
Y
Y
Y
Y
Y
Description
RIGHT
LEFT
ANTERIOR
POSTERIOR
MEDIAL
LATERAL
OTHER
BODY PARTS
15
Active
Y
Y
Y
Y
Y
Y
Y
Y
Y
Required
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Description
BACK OF HEAD
EAR
SCAPULA
ELBOW
VERTEBRAE
SACRUM
COCCYX
ILIAC CREST
HIP
ISCHIAL
TUBEROCITY
THIGH
KNEE
LEG
ANKLE
HEEL
TOE(S)
OTHER
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5. “NO ADDITIONAL” DIAGNOSIS (on add-on / evaluation visits ONLY)
On an evaluation visit, if there is not an additional diagnosis specific to your
discipline that was NOT added to the start of care, you now have the ability to add
a generic ‘no additional’ code, which will allow you to get the asterisk next to
‘diagnosis’, so you can complete the visit.
1.
2.
3.
4.
Tap ‘diagnosis’ in right upper quadrant
Tap ‘ADD’ (lower left)
Tap ‘ADD’ (upper right)
Scroll to the bottom of the ICD-9 codes, and select the “no ad” for your
discipline
5. Tap ‘OK’
a. You must address severity and exacerbation date
6. Choose ‘0 – asymptomatic’ for symptom control
7. Choose ‘exacerbation’ and add the date of the current visit
We have requested this option be made available to Pastoral Care, Music & Reiki,
which will be available at a later date.
6. REMOVAL OF “PHYSICIAN NOT IN SYSTEM”
Due to Oasis-C requirements (M0118) ‘physician not in system’ has been removed
from the system. The Oasis requires the attending physician’s NPI number
therefore a physician must now be added to the Oasis.
ALL FIELD STAFF MUST REFRESH THEIR TABLES AT LEAST WEEKLY – IN
ORDER TO HAVE THE MOST CURRENT PHYSICIAN LIST AVAILABLE ON PDA.
CALL THE HELPDESK FOR ASSISTANCE WHEN YOU ARE READY TO REFRESH
DO NOT ATTEMPT TO DO THIS IF YOU ARE UNSURE – PLEASE CALL THE
HELPDESK FOR TECHNICAL ASSISTANCE.
7. PAIN DOCUMENTATION
Pain is “the 5th vital sign”, therefore MUST be assessed by ALL skilled disciplines,
on EVERY visit.
Please start using the pain scale in the vital signs section in Point Care, to
document patient’s pain level.
Remember, if you add the pain rating to vital signs, it will be available for you, and
any other clinician visiting, in the ‘home communication log’ under the ‘client’
menu.
ALL skilled field staff will be expected to start adding pain scale rating in the vital
signs area.
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New NDPs
Due to Oasis-C requirements, some new NDPs were created in order to better measure
outcomes and to give field clinicians an easier way to view specific interventions and goals.
1. NEED FOR SKILLED ASSESSMENT AND TEACHING RELATED TO FALL
PREVENTION
This NDP will be used with the fall prevention process (see page 3). For any patient
with the ICD-9 code of V-15.88, this NDP will direct the clinician to select it in order
to complete the visit. ALL skilled disciplines are required to address fall risk.
Please note the discipline specific NDP numbers:
RN - # A103
PT - # B103
OT - # D103
ST - # C123
2. NEED FOR SKILLED NURSING ASSESSMENT – DIABETIC FOOT
SCREENING
This NDP is to be used for ALL diabetic patients (controlled/uncontrolled) with an
ICD-9 code of diabetes anywhere in the diagnosis list.
RN - # A572
3. NEED FOR WOUND CARE – PRESSURE ULCER(S)
Same as general ‘wound care’ NDP but specifies pressure ulcer.
RN - # A402
4. NEED FOR SKILLED TEACHING RELATED TO PRESSURE ULCER(S)
Same as general ‘wound teaching’ NDP but specifies pressure ulcer.
RN - # A406
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DEPRESSION SCREENING
NDP: NEED FOR ASSESSMENT OF PSYCHOSOCIAL STATUS # A670 – RN ONLY
Due to Oasis-C requirements, all patients must be screened for depression and
documentation must reflect interventions and follow up.
If you identify depression, based on the PHQ-2 screening results, you MUST select this
NDP, as it contains interventions and goals specific to depression.
Please see the SBAR script below which was created to assist you when you need to inform a
physician concerning a depressed patient.
Please consult with your Manager concerning process related questions regarding
depression screening and need for follow up.
SBAR and a score of 3 or more on the PHQ-2
depression screening in OASIS-C
S
Hi Dr. _____, My name is Sue Smith. I am a registered nurse with VNACJ
who visits Mr. Jones at home. In doing the admission assessment today, I
screened him for depression using a standard tool called the PHQ-2. His
score was 3, which is considered positive, indicating he may have symptoms
of possible depression, and further action should be taken.
B
Mr. Jones has been widowed about 2 years now. His daughter who lives in
Florida was visiting for a week but left about 2 weeks ago. We are seeing
him for skilled nursing care related to his diabetic foot ulcer and
management of his diabetes.
A
Mr. Jones is ambulating around his house and completing his activities of
daily living. He does report difficulty sleeping at night.
R
Would you like me to get a referral for a social worker to see Mr. Jones? Or,
should he make an appointment to see you soon?
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HOSPICE
This is a reminder for all Hospice field staff responsible for addressing
bereavement risk.
The Bereavement Risk Assessment form that has been set up for use by Hospice
customers is now being sent to Point Care for documentation. Because risk
assessments are tied to a Hospice patient’s bereavement contacts, this new feature is
found within the Contacts section [under Demographics] of Hospice visits.
This feature replaces the need to document the risk assessment in a coordination note.
Upon synchronization of the visit, the bereavement module will be updated to reflect a
risk assessment was performed and bereavement workflow will also generate according
to the risk assessment score.
An ‘Assess’ button has been added to the Contacts screen and will be enabled for all
contacts where the ‘Bereavement Contact?’ flag is set to Yes. A column has also been
added to the screen to indicate if the contact is a bereavement contact.
To assess, select the contact and tap Assess to open the form.
The risk assessment questions appear in the same format as found in physical
assessment. Tap Yes or No to move through the form.
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The risk score is automatically calculated upon answering the final question. Note: The
risk level will be added to this form in a future release.
Utilize the existing Form Summary feature to see how the questions were answered.
21
OASIS-C “look back” features in Point-Care
A. Plan/Intervention: “Look Back” Feature Added for New OASIS-C
Questions
A new “Look Back” feature has been added in the “Physical Assessment”
section in PointCare to provide nurses with easy access to the answers
(M2250) that were given during the SOC/ROC, so they are able to best
answer questions (M2400) during the DC/Transfer. These are new OASIS-C
standardized questions and answers.
The following list of questions will have the “Look Back” link for reviewing the
subsequent answers:
OASIS Questions and Possible Answers:
(M2400) Intervention Synopsis – Plan / Intervention
A. Diabetic Foot Care
B. Falls Prevention Intervention
C. Depression Intervention
D. Intervention to Monitor and Mitigate Pain
E. Intervention to Prevent Pressure Ulcers
F. Pressure Ulcer Treatment Based on Moist Wound Treatment
(M2250) Plan of Care Synopsis – Plan / Intervention
A. Patient Specific Parameters
B. Diabetic Foot Care
C. Falls Prevention Interventions
D. Depression Interventions
E. Pain Interventions
F. PU Prevention
G. PU Moist Treatment
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B. Diagnoses/Procedures: Modifications for OASIS-C
The following four changes have been made to the “Diagnoses/Procedures”
form in both HCHB and PointCare to accommodate OASIS-C requirements,
as well as to accommodate needs for all service lines, i.e. Diagnoses and
procedure codes were originally based on M0 numbers, which are not used
with the Hospice service line.
1) The M0230 label for Primary Diagnosis has been changed to “Primary
Diagnosis”.
2) The M0240 label for Secondary Diagnosis has been changed to “Other
Diagnosis”.
3) The M0240 label for Procedures has been changed to “Procedure”.
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4) The “Severity” label has also been changed to “Symptom Control Rating”
for OASIS-C purposes.
Note: Users will notice that the “Symptom Control Rating” selector will
disappear when a “V” or “E” diagnosis code is selected because they are not
required.
C. Goals: “Look Back” Feature to Reference Related Intervention/Details
AI new “Look Back” feature has been added to the “Goals” section in
PointCare to provide users with the ability to reference the Intervention
related to the Goal, the response to the Intervention, as well as the
Intervention details that were entered. This update was implemented as a
way to assist nurses in easily determining the Intervention that created the
need for the goal.
Steps to access the “Look Back” feature:
- Click the “Goals” link from the “Visit” quadrant within PointCare
- Click any Goal to display the “Look Back” link
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- Click the “Look Back” link to view the Intervention information
- Click “Close” to go back to the Goal question
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