Clinical Document Flow Pattern

The table below contains the complete list of hospice clinical documents in HEALTHCAREfirst :

* The Hospice Aide Care Plan flows to the Hospice Aide Visit Note. If the clinician indicates certain tasks to be performed by the aide on the care plan, the visit note flags those tasks as “to do” items so the aide knows specifically which tasks are to be performed. The Hospice Aide Visit Note displays two asterisks (**) next to the tasks that were indicated on the Hospice Aide Care Plan.

The remaining Defaulting Flow Clinical Documents are divided into two (2) categories:

The following table contains a comprehensive listing of the flowing deficits and the clinical documents in which they are found.

‡ Depending on your processes, these areas may be controlled by MSW or Spiritual documents only, and editing the care planning items (problems, interventions, and goals) may be prevented in nursing documents. When completing nursing documents in this situation, clinicians can use the Coordination of Care page to communicate visit observations and suggest care plan updates for these areas.

The best way to describe the flow of deficit information between the Default Flow Clinical Documents is to give an example of a possible scenario. Use the diagram below (Figure 19) to assist you in understanding this scenario:

● A patient has elected to receive Hospice. The Nurse makes the initial visit to patient’s home, completes the Initial Nurse Assessment and locks the document.

● A Nurse then makes the first subsequent visit and creates a Nurse Visit Note. The deficit information (Problems, Interventions and Goals) from the Initial Nurse Assessment flows to the Nurse Visit Note created. The Nurse updates the information on the Nurse Visit Note as necessary and then locks the document.

● Next, the Chaplain makes a visit to the patient’s home and creates the patient’s Spiritual Assessment. Upon creation, the Spiritual Concerns deficit information flows to the newly created Spiritual Assessment from the locked Nurse Visit Note. The chaplain then reviews, updates and locks the document.

● Within the next few days, a Social Worker makes a visit to the patient and creates a Medical Social Worker Assessment. Upon creation, the Coping/Knowledge deficit information flows into the Assessment from the recently locked Nurse Visit Note. The Social Worker reviews, updates and locks the Medical Social Worker Assessment.

● Within the first 14 days an IDT Plan of Care (POC) is created for the patient. Upon creation, the Spiritual Concerns deficit flows in from the locked Spiritual Assessment; the Coping/Knowledge deficit flows in from the Medical Social Worker Assessment; and the remaining deficits flow in from the most recently locked Nurse Visit Note.

● Next, the IDT POC Update is created. Upon creation the Spiritual Concerns deficit flows in from the locked Spiritual Assessment; the Coping/Knowledge deficit flows in from the Medical Social Worker Assessment; and the remaining deficits flow in from the locked IDT Point of Care (POC).

● In subsequent Nursing Visit Notes, the Nurse cannot change the Spiritual Concerns or Coping/Knowledge deficits, but can add Narratives in the Coordination of Care page about these areas. The Care Coordination information flows to the IDT Plan of Care for review by all disciplines.

DEFAULTING FLOW CLINICAL DOCUMENT DEFICITS
Deficits	Comprehensive Documents				Specialty Documents
Deficits	Initial Nurse Assessment	Nurse Visit Note	IDT POC	IDT POC Update	Spiritual Assessment	Spiritual Visit Note	Medical Social Work Assessment	Medical Social Work Visit Note	PRN Progress Note	Case Communication
Cardiovascular	P	P	P	P
Respiratory	P	P	P	P
Physical Comfort/Pain	P	P	P	P
Sleep	P	P	P	P
Integument/Skin	P	P	P	P
Wound 1	P	P	P	P
Wound 2	P	P	P	P
Wound 3	P	P	P	P
Wound 4	P	P	P	P
Elimination/Urinary	P	P	P	P
Nutrition	P	P	P	P
Musculoskeletal	P	P	P	P
Neurological	P	P	P	P
Gastrointestinal	P	P	P	P
Endocrine	P	P	P	P
Environmental Safety	P	P	P	P
Grieving Anticipatory/ Bereavement Assessment ‡	P	P	P	P			P	P
Spiritual Concerns ‡	P	P	P	P	P	P	P	P
Coping/Knowledge ‡	P	P	P	P			P	P
Activities of Daily Living	P	P	P	P
Coordination of Care	P	P	P	P	P	P	P	P	P	P

Clinical Document Flow Pattern

Document Name

Document Type

Defaulting Flow Clinical Documents

Document Name	Document Type	Defaulting Flow Clinical Documents
Initial Nurse Assessment	Assessment	P
Medical Social Work Assessment	Assessment	P
Spiritual Assessment	Assessment	P
Discharge Summary	Assessment
Hospice Aide Care Plan	Care Plan	*
Initial Plan of Care/Physician’s Orders	Care Plan
Palliative Performance Scale	Care Plan
IDT Plan of Care (POC)	Care Plan	P
IDT Plan of Care (POC) Update	Care Plan	P
Nursing Visit Note	Visit Note	P
Hospice Aide Supervisory Visit Note	Visit Note
Hospice Aide Visit Note	Visit Note
Medical Social Work Visit Note	Visit Note	P
Counselor Note	Visit Note
Spiritual Visit Note	Visit Note	P
PRN Progress Note	Visit Note	P
Telephone Progress Note	Visit Note
Medical Director Progress Note	Visit Note
Nurse Practitioner Progress Note	Visit Note
Physician Progress Note	Visit Note
Death Visit Note	Visit Note
Volunteer Visit Note	Visit Note
Inpatient Facility Rounds Visit Note	Visit Note
Imminent Status Review	Supporting
Fall Risk Screening (Multi-Factor)	Supporting
Braden Scale	Supporting
Case Communication	Supporting	P