Understanding the Document Layout

The Document grid on the Documents tab contains created documents, and includes the following information:

●     Document Name

●     Reason

●     Visit Date

●     Date Created

●     Date Modified

●     Completed  - True or False

●     Date Completed (If the document has been completed)

●     Locked - True or False

●     Date Locked (If the document has been locked)

●     Date Submitted

●     Date Printed

 

The first page on many clinical documents is the T (Trending) Page. The T Page flows from all previous documents that have information in these sections, displaying history or trends of recent documents, and includes the following data:

●     Patient ID (with Fastlink to Med Profile)

●     Patient Name

●     Today's Date/Episode Date (if applicable)

●     Previous Documents

●     Previous Visit Date

●     Previous Document Created By

●     Previous Temperature

●     Previous Pulse apical

●     Previous Pulse Radial

●     Previous Respiratory

●     Previous Pt Inr

●     Previous Blood Pressure: Left - Lying, Sitting, Standing

●     Previous Blood Pressure: Right - Lying, Sitting, Standing

●     Previous L/R Not Specified: Lying, Sitting, Standing

●     Previous Present Level of Pain

●     Previous Acceptable Level of Pain

●     Previous Pulse Ox

●     Previous Weight

●     Previous Body Circumference: Body Left - Arm, Thigh

●     Body Circumference: Body Right - Arm, Thigh

●     Previous Wound 1: Stage, Size, Length, Width, Depth

●     Previous Wound 2: Stage, Size, Length, Width, Depth

●     Previous Wound 3: Stage, Size, Length, Width, Depth

●     Previous Braden Scale Total

●     Previous Supervision

 

The second page on many clinical documents is the CPS (Care Plan Summary) Page. The CPS Page flows from all previous documents that have information in these sections, and contains the following data:

●     Patient ID (with Fastlink to Med Profile)

●     Patient Name

●     Today's Date/Episode Date (if applicable)

●     Previous Assessment Summary

●     Previous Goals

●     Previous Progress Toward Goals

●     Previous Plan for Next Visit

●     Previous Discharge Planning

●     Previous Care Coordination

 

You can print the individual previous reports listed on the CPS Page:

1.    Click Print Report to open the report in a new window.

2.    Click Print.

3.    To close the window and return to the CPS Page, click Close.

The first document created in the patient's chart will not have any information in the T Page or CPS Page fields since there is no previous documentation in the system.

 

The Document page on clinical documents contains the body of the document with all questions in a scrolling format in sections. Scroll down the document to access all questions in the document. Some data will flow from the Patient Chart to the document.

 

The 485 Page contains 485 questions. The information you enter on the 485 page flows to the plan of care once the document is locked.

 

The S1 Page contains the HHRG Summary - Oasis C. If you did not complete enough questions to give an HHRG score, the system displays a green message at the top right of page stating "Insufficient Information to Calculate HHRG/HIPPS" and notes the questions you must answer before a score can be calculated.

 

The Visit Details (P-Page) contains the Clinical Document Charge Entry. The Visit Details page includes the following sections:

●     Visit

o     Visit Date

o     End Visit Date

o     Order/Auth

o     Scheduled

o     Description

o     Location

o     Personnel

o     Payor

o     Visit Duration

§      Begin Time

§      End Time

§      Visit Duration (Hours, Minutes)

§      Time Not Recorded checkbox

To account for agencies that do not use the integrated scheduling features, the software automatically assigns a Payor in the Visit Details page. This ensures each that a payor is assigned to each P Page, for agencies that use clinical documents, but choose not to create and assign a visit for the document: If a scheduled visit is not selected when the P Page is saved, the software will automatically assign the primary payor that is designated in the patient chart. All payors associated with the patient will display in the Payor drop-down menu, which allows users to edit the P Page based on security settings (as necessary). If a scheduled visit is selected when the P Page is saved, the software will use the current procedure to determine payors available for selection in the Payor drop-down menu. This is based on the Billing Seq established for each insurance record in Patients | Intake / Referral | Insurance. When the next release of multipayor functionality is available, the software will use payor coverage dates to determine which payors display in the Payor field. This is why agencies must ensure that the effective dates for all patient insurance records are correct. If a user assigns a visit to the P Page later, the software will prevent any visits from being associated with a payor that is not in effect. Agencies that utilize the "Scheduled visit required" checkbox are not impacted.

●     Travel Duration

o     Travel To Duration

§      Begin Time

§      End Time

§      Duration (Hours, Minutes)

§      Time Not Recorded checkbox

o     Travel From Duration

§      Begin Time

§      End Time

§      Duration (Hours, Minutes)

§      Time Not Recorded checkbox

●     Office Duration

o     Begin Time

o     End Time

o     Office Duration (Hours, Minutes)

o     Time Not Recorded checkbox

●     Other Duration

o     Begin Time

o     End Time

o     Other Duration (Hours, Minutes)

o     Time Not Recorded checkbox

●     Mileage

o     Mileage:

§      To (Begin, End)

§      From (Begin, End)

For each field, enter the specific mileage amount that is displayed in your vehicle's odometer before beginning that part of the drive. For instance, if your odometer read "124,392" before driving to visit the patient, then you would enter "124392" in the field that is under the "Begin" column and is also in the "To" row. The "To" row represents vehicle mileage for the trip towards the patient visit and the "From" row represents mileage for the return trip back from the patient visit.

§      Recalculate button— When clicked, the software will automatically calculate the mileage totals based on the specific mileage amount (as displayed in your vehicle's odometer) that are entered in the "Begin" and "End" columns (for the "To" row; the drive to the patient) and the amounts that are entered in the "Begin" and "End" columns (for the "From" row; the return drive back from the patient's location). The Total Miles driven for the patient visit will display underneath the fields (to the left of the Recalculate button).

o     Mileage Not Recorded checkbox

●     Negative Pressure Wound Therapy

o     Duration for placement/replacement of a dNPWT mgmt. collection system (Hours, Minutes)

o     Choose size of pressure wound:

§      Surface area<=50cm

§      Surface area>50cm

For additional information about functionality related to negative pressure wound therapy, refer to the 16.11.1 release guide.

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