PATIENT ENCOUNTER CLINICAL TAB

Under the Patient Encounter "Clinical Tab" you will find the following options:

Clinical Team
Disciplines
Specialty Skills
Programs
Vendors
Vaccines
Disaster Plans
Advance Directives
Consent and Notices
DME
Vital Signs Parameters

CLINICAL TEAM (Top)

The Clinical Team allows you to assign different team members to the patient such as case manager and clinical manager for this patient. This information was set up when the patient was activated but if not, click on the "Edit" link to change or update information as required. The Work Basket allows you to filter by Team.

Choose the Case Manager and Clinical Manager and click "Save" when finished.

ADD TO CLINICAL TEAM (Top)

To add other associates to the team, click on "Add to Clinical Team".

Choose the associates you want to add to the team and then indicate which associate is the primary for that specific discipline. In the Hospice Environment, you can also indicate which nurse is the "Admitting Nurse" as well. Click "Save" when finished.

EDIT CLINICAL TEAM (Top)

To edit the Clinical Team, click on the "Edit" link.

Make the necessary changes and click "Save" when you are finished.

DISCIPLINES (Top)

Displays all disciplines that are required for the patient’s care. The initial disciplines are pulled from the referral and are updated as additional disciplines are entered when creating the 485 and interim orders.

ADD SPECIALTY SKILLS (Top)

Displays any specialty skills required to care for this patient. The specialty skills were set up during the referral process. To add a skill for the patient, click on "Add Specialty Skill".

NOTE: For Careficient Agency Administrators, “Specialty Skills” options can be set in Settings > Lookup Tables > General Support Tables > Skills.

Choose the specific skills for the patient.

EDIT SPECIALTY SKILLS (Top)

To edit Specialty Skills, click on the "Edit" link.

Make the necessary changes and click "Save" when you are finished.

ADD PROGRAMS (Top)

Displays specialty programs to which this patient is admitted to service. To add a Program, click on "Add Program".

NOTE: For Careficient Agency Administrators, “Program Type” options can be set in Settings > Lookup Tables > Patient Support Tables > Program Type.

Choose the Program Type and click "Save" when finished.

EDIT PROGRAMS (Top)

To edit a Program Type, click on the "Edit" link.

Make the necessary changes and click "Save" when you are finished.

ADD VENDOR (Top)

You can identify all vendors used to provide equipment, supplies and any medications for an individual patient. For vendors to appear in the dropdown list, you must add them to your referral sources as a facility and identify the type of business (DME, Pharmacy, etc). If you would like the pharmacy you listed on the Clinical tab to automatically populate the “Pharmacy” field when you add medications, you will need to activate a the agency rule “Apply Pharmacy vendor when adding meds”. To add a vendor, click on "Add Vendor".

Enter the required information and click “Save”.

EDIT VENDOR (Top)

Click on the "Edit" link to edit the Vendor.

Make the necessary changes and click "Save" when you are finished.

To view the vendor contact information, click on the address book.

The address information pops up.

ADD VACCINES (Top)

You can keep track of any vaccinations that patients receives. To add a vaccines, click on "Add Vaccines".

NOTE: For Careficient Agency Administrators, “Vaccines” options can be set in Settings > Lookup Tables > Clinical Support Tables > Vaccines.

Select a vaccine from the drop down listing. Enter a date and select "Save".

EDIT VACCINES (Top)

To edit the vaccine information, select the "Edit Vaccine" icon.

Make the necessary changes and click "Save" when you are finished.

DELETE VACCINES (Top)

To delete a vaccine, select the "Trash Can".

You will be asked if you are sure you want to delete. Click "OK" to confirm.

ADD DISASTER PLAN (Top)

Identify the current disaster level information for the patient, including individualizing the disaster plan comments specific to this patient. To make any changes to the Disaster information, update the Clinical tab for that section. Service Note forms that include the Disaster plan information will also update the Clinical tab, Disaster Plans section. The Service Notes that contain this section include:

Start of Care Assessment
Resumption of Care Assessment
Recert Assessment

You can see Disaster Level information as part of the Patient Encounter header section (referred to as Basic Information section). No matter what tab you select, you will see this information as part of the Patient Encounter heading. The Disaster Plan information documented on the Clinical tab flows into your initial Physician Orders for each certification period.

To add a Disaster Plan, click on the "Add Disaster Plan" link.

NOTE: For Careficient Agency Administrators, “Disaster Plan” options can be set in Settings > Lookup Tables > Patient Support Tables > Disaster Plan Type. Click on the following to learn more about the privileges for View Encounter Disaster Plans.

Enter the required information and click “Save”.

EDIT DISASTER PLANS (Top)

Click on the "Edit" link to edit the Disaster Plan.

Make the necessary changes and click "Save" when you are finished.

ADD ADVANCE DIRECTIVES (Top)

Displays specific advance directives required to care for this patient. To add an Advance Directive click on the "Add Advance Directives" link.

NOTE: For Careficient Agency Administrators, “Advance Directives” options can be set in Settings > Lookup Tables > Patient Support Tables > Advance Directive Type.

Enter the required information and click “Save”.

EDIT ADVANCE DIRECTIVES (Top)

Click on the "Edit" link to edit the Advance Directive.

Make the necessary changes and click "Save" when you are finished.

UPLOAD ADVANCE DIRECTIVES (Top)

You can upload the Advance Directive Document into the Documents Tab that links to this section. The description comes from the uploaded document description for the Advance Direction along with the date it was uploaded.

EDIT CONSENTS AND NOTICES (Top)

Home health organizations typically have several consents and notices that patients receive or sign to ensure that they understand and agree to the terms under which care will be delivered. This section displays the pertinent consents and notices as set up and required by your organization. When a referral is created, the Consents and Notices auto-populate with the following. Click on "Edit" link to make the changes.

You can upload the Consent form into the Documents Tab and it will link to this section. The description comes from the uploaded document description for the Consent form along with the date it was uploaded. The description in this section is a link to open the document so that you don’t have to go to the Documents tab to look at it.

Make the necessary changes and click "Save" when you are finished.

ADD DME (Top)

Displays DME items required for the patient encounter. This section includes the type of equipment, DME vendor, delivery and return dates for the equipment and a comments field. To add equipment, select the Add DME link. This option is only used for agencies that need to keep up with DME that they disperse to patient. It is not used to list what DME the patient has as it will generate a Work Basket item until there is a "Return Date" entered for the DME.

Enter the required information and click “Save/Add More” to add more DME or "Save/Close".

EDIT DME (Top)

Click on the "Edit" link to edit the DME.

Make the necessary changes and click "Save" when you are finished.

DELETE DME (Top)

Click on "Delete" to delete the DME.

You will be asked if you are sure you want to delete. Click "OK" to confirm.

ADD DEFAULT VITAL (Top)

You can document acceptable ranges for all patient vital signs and receive warning messages as well as Work Basket events when a patient’s vital signs are outside the parameters you identified. Areas of the application impacted by this change include:

Tables options 
Patient Encounter, Clinical tab 
Physician Orders 
Service Notes 
Work Basket

Tables

You can enter and/or update vitals signs parameters for each Patient Encounter. Service Notes that contain vital signs will be matched to the these parameters to determine if the patient is not within the acceptable parameters and provide you with alerts as well as Work Basket events. To enter/update vital sign parameters: Patients > Patient Encounters > Find/Select a Patient  > Clinical tab. Vital Signs Parameters uses a “Vital Type” table that contains the low and high values for each vital sign listed. We provide you with the “default” parameters that you can change or you can add a new vital sign that is not currently listed in the table.

NOTE: For Careficient Agency Administrators, “Vital Type” options can be set in Settings > Lookup Tables > Clinical Support Tables > Vital Type

Select the Add Default Vital link 

Change any of the low/high values as necessary 

Select the Save button 

EDIT VITAL SIGN PARAMETERS (Top)

You can also make changes to existing vital sign parameters by selecting the “Edit” icon.

If you do not want to continue checking parameters for a specific vital, select the “Delete” icon to remove it from the list.

Click here to learn more about Vital Signs Parameters in the 485 and Vital Signs in the Service Note.