Enhanced Documents

Enhanced documents are now available for all hospice agencies. Each of the enhanced documents use a completely new format, enabling users to easily enter patient information in the assessment forms, as necessary. Interactive forms are designed to decrease the amount of time clinicians spend completing documentation. Learn about using the new documents on page 15.

Several of the enhanced documents are completely new, but many of the new documents are existing documents (e.g. Face to Face Physician Encounter, Death Visit Note) that have been upgraded to the newer, advanced format. Agencies must setup a document list for each office (See “Setting Up the Document List” on page 10) regardless of document version. The following section contains a complete listing of the enhanced documents that are now available.

List of New Documents

The list below contains specific names of all the new, enhanced versions of hospice documents that are now available. Any of the following documents that are enabled for an office (in Reference Files | Document Exclusion) will be available for selection in the Select a Document menu (in Patients | Documents), with the exception of the IDT Meeting document, which is only accessible from the IDT Meeting tab:

An asterisk (*) indicates the document is completely new and there was no previous version that has been replaced. For instance, the Death Visit Note is a new, enhanced version of the previous Death Visit Note, but the Death Summary is a completely new document that is now available.

● Case Communication

● Counselor Note

● CTI - 60 Day (*)

● CTI - Initial 90 (*)

● CTI - Second 90 (*)

● Death Summary (*)

● Death Visit Note

● Face to Face Encounter

● HIS - Admission

● HIS - Discharge

● IDT Discipline Narrative (*)

This functions with the new IDT Meeting tab. This can be created, viewed, or deleted from either of these screens.

● IDT Meeting (*)

This document can only be accessed from the IDT Meeting tab.

● Inpatient Facility Rounds Visit Note

● Live Discharge Summary

● Medical Director Progress Note

● MSW Assessment

● MSW Initial Assessment

● MSW Visit Note

● Nurse Practitioner Progress Note

● Physician Progress Note

● Plan of Care - Physician's Orders (*)

This replaces both the Initial Plan of Care/Physicians Orders and Recert Plan of Care/Physicians Orders, as users are now able to indicate whether the plan of care is initial or recertification.

● PRN Progress Note

● SN Assessment (*)

● SN Initial Assessment (*)

● SN Visit Note (*)

● Chaplain Assessment (*)

● Chaplain Initial Assessment (*)

● Chaplain Visit Note (*)

● Telephone Note

● Volunteer Visit Note

The Name of each document in Reference Files | Document Exclusion matches the name that displays in Patients | Documents. Users can determine that an entry is a CAREpliance document by hovering the mouse cursor over the document listed in the Select a Document drop-down menu. A "Compatible with Care Planning" message will display for the newer, enhanced versions of documents.

Enhanced documents are designed so patient data can be entered using one continuous interface. Users can proceed through documents by navigating to the next part of the assessment, instead of clicking through numerous tabs at the top of the screen. Enhanced documents are designed with a higher level of usability, enabling clinicians to spend less time on documentation.

Aside from the specific features that are detailed on the following pages, listed below are some of the notable features that are included within the enhanced documents:

● Information saves automatically as users complete documents.

● Compatible with care planning features.

● Synchronizes with Document Tracking.

● Custom forms are no longer necessary. Optional sections of data can be added, as necessary.

● Easily move to different sections of the document using a built-in navigation menu.

● Select which parts of the assessment display, as all sections of data are collapsible

● Multiple signatures feature enables agencies to gather several signatures electronically.

● MAHC-10 Fall Risk Assessment and Braden Scale are included within applicable documents.

● Some patient information populates automatically within applicable fields of the document, based on data present in the patient chart (e.g. Admission Date, Diagnosis, Birthdate, Allergies ).

● Color-coded indicators indicate the relevance of certain parts of the assessment:

o Dataflow — Fields that populate data automatically (i.e. text fields, checkboxes, radio buttons, drop-down fields, etc.) from the patient chart will display with pink font.

o HIS — Assessment questions related to the Hospice Item Set (HIS) will display with blue font.