ADD PAGED SERVICE NOTE/ASSESSMENT (HOME)

To add a service note, whether it's for nursing, therapy, HHA's, etc., click on "Add Paged Service Note/Assessment.

NOTE: For Careficient Agency Administrators, click on the following to learn more about the privileges for Add Service Note Assessment.

OASIS VERSES REGULAR ASSESSMENT (Top)

When adding service notes, there are 2 options:

OASIS integrated assessment
Regular assessment

Choose Oasis Integrated Assessment for any visits that require an OASIS (Typically, Medicare, Medicaid, and Medicare/Medicaid Advantage plans require the OASIS form to be completed) and Regular Assessment for visits that do not require OASIS. Click Continue.

NOTE: For Careficient Agency Administrators, click on the following to learn more about the privileges for Add Oasis.

ACTIVATE PATIENT (Top)

If you are doing a Start of Care visit, you you will enter your admission information. In this screen the “Verbal SOC” date refers to the date that you called the physician and notified him of your findings and his approval of the admit and your orders. Once you have entered the information, click “Save”.

NOTE: For Careficient Agency Administrators, “Admission Source” options can be set in Settings > Lookup Tables > Patient Support Tables > Admission Source. Also for "Teams", see Settings > Lookup Tables > General Support Tables > Teams.

Choose your service code. These depend on your agency settings. FYI – when you click on your option, the screen will refresh before you can choose “Continue”. Choose the Service Note Type. These also depend on your agency settings. Click “Save”. Your assessment will then open up and you can begin to fill it out.

NOTE: For Careficient Agency Administrators, “Service Code” options can be set in Settings > Lookup Tables > General Support Tables > Services Codes.

NAVIGATING THE SERVICE NOTE ASSESSMENT (Top)

Data Entry for Service Notes now have three tabs at the top of the screen:

Service Note
Orders
Medications

SERVICE NOTE TAB (Top)

ORDERS TAB (Top)

MEDICATIONS TAB (Top)

Click here for more information on how the Medication's Tab works.

CHANGE SECTION (Top)

This allows you to flow from one section of the assessment to another without having to page through each section using the “Next” button. (choosing a different section does save the information on the section you just entered before going to the next section).

If you click on the drop down to the right of the "Header and supplies", you will see each section contained within the service note as below. The sections you see depend on your agency settings.

VIEW OTHER NOTES AND ASSESSMENTS (Top)

This allows you to view all previously entered service note/assessments. You will not see any on a SOC as it is the first visit.

NEXT (Top)

This allows you to move forward from one section to the next (clicking next does save the information on the section you just entered before going to the next section).

PREVIOUS (Top)

Once you click on next, you will also have an option for previous.

SAVE/CLOSE (Top)

This will save your assessment and close it without completing or approving the assessment. You will be able to edit the assessment at a later date.

ANALYZE (Top)

This analyzes your assessment for errors prior to approving your assessment. (Recommend not running analyze until most of your assessment if completed as it will bring up multiple errors and take quite some time to complete because of this).

Messages types include the following:

Inconsistency flag – Lists responses that are inconsistent or that conflict with other responses.
Warning - Encompasses consistency, invalid values, and range errors.
Outcome potential – Indicates that the response to this item could affect outcome measures.
Process measure audit – Indicates where and how a best practice standard of patient care was not met.
Compliance risk audit
Grouper validation audit – Indicates an issue with validation of MS-DRG and APR DRG grouper-significant ICD-9-CM codes.
Fatal audit – May result in the rejection of an OASIS record.

Where appropriate, the OASIS Validation Report indicates corrective action. The OASIS analysis tool can help improve clinical documentation and clinical scores. This in turn can increase your agency’s revenue and reimbursement rates.

APPROVE/COMPLETE (Top)

The option that you will see here depends on your agency settings. If you do not have permissions, the Approve button does not display. Complete will complete your assessment for someone else to review and approve. You assessment will no longer be editable unless your supervisor marks the visit as “Incomplete” again for you.

NOTE: For Careficient Agency Administrators, click on the following to learn more about the privileges for Approve Service Note Assessment.

When you click Approve, Careficient displays a list of errors (in red). Each error message has a corresponding error number. The errors are related to locators and the OASIS data itself. They are not related to skilled assessments. Click the error to navigate to the section you need to correct. You must correct all errors.

CANCEL (Top)

This will close the assessment without saving it but will still leave an assessment attached to your visit that you can edit at a later date.

VIEW INTEGRATED ASSESSMENT (Top)

View Integrated Assessment will allow you to view a continuous PDF of the entire assessment.

APPLY ON-DEMAND SECTIONS (Top)

Apply On-Demand Sections allows you to add specific sections to your note that you may not always want to appear in the entire note.

For instance, we have many different types of wound sections that do not show up in the note unless you apply them as an on demand section. Once you add this section, it will stay in the note until it is removed by clicking on the Apply On-Demand Section and unchecking that specific section. Here we only have an example of a Pain Assessment to add.

SECTION TITLE (Top)

Every section of the service note has a blue title bar. If you ever need to request changes be made to your notes, always include the section bar title in your request as well as the changes you are requesting be made.

HEADER AND SUPPLIES (Top)

The date of your service (visit) is noted in the top left corner of the Header and Supplies screen.

The type of service note (assessment) is also included in the Header and Supplies screen. Please note, if you do not have the correct type of service note (assessment) here, you will have to delete the service note and add the correct one. To prevent loss of information, make sure that this is the correct type of service note (assessment). It cannot be changed later.

The status of your assessment is included in the Header and Supplies screen.

The patients name is included in the Header and Supplies screen.

The Medical Record Number is included in the Header and Supplies screen.

The patient's DOB is included in the Header and Supplies screen.

You will enter your time in/out and duration in the Header and Supplies screen. You can enter the time you started the visit and leave the “Time Out” field blank until you complete your visit. Be sure to go back and enter the time in this field as you will not be able to complete/approve the Service Note. Information from the time slip portion of the service note can flow to payroll.

The associate's name and discipline are also included in the Header and Supplies screen.

Travel duration/miles and type can also be entered in the Header and Supplies screen.

Services performed refers to the type of service code you are billing the claim with and it also is included in the Header and Supplies screen. If this is incorrect, it can be changed at a later date when the visit is verified.

The comments are flows to the service notes tab in the patient encounter and can been seen at a glance by hovering over the yellow piece of paper after the QA Status column. Most agencies use this for documenting things like a brief example of what was taught on the visit so that the nurse can view this without opening up the service note.

PATIENT SIGNATURE (Top)

Patient Signature is a drop-down box where the associate can choose which type of patient signature they are adding. Options include: Electronic, Not Required, and Paper.

If you choose "Electronic", you will then have the option to "Enter Signature" of the patient.

The patient can then sign and accept the signature. If you need to clear the signature for some reason and allow them to try again, you can click on "Clear". When you are satisfied with the signature, click on "Accept". The system will not allow you to enter the patient's signature unless you have your time in and out entered.

ADD SUPPLY (Top)

The "Add Supply" link allows the nurse to add any supplies that they have taken to the patient.

You can see here how easy it is to add the supplies to the patient visit. You just click the drop down and select the supply and then enter the amount of units. You can "Save/Add More" or "Save/Close". If you decided you didn't want to add any supplies you could choose "Close".

MEDICATION ADMINISTRATION (Top)

Medication Administration (Video)

Once the visit note is completed, the meds will flow to the meds tab. To setup medication administration, click on the "Med Admin" link. You also have the ability to setup Med Admin and document Med Taken from the Medications Tab in the patient encounter.

NOTE: For Careficient Agency Administrators, the "Med Admin" link is based on your agency settings but if your agency has activated this, you will be able to document medications administered/taken by the patient.

Careficient Employees click here to learn more about Setting up Medication Administration.

You will be able to adjust when the meds should be taken by clicking on the lock for each medication.

Under "Hour", you can change the wording to up to 4 time slots for the specific medication.

Enter the dates that you want to schedule the meds to be taken and click "Apply" button if you want Careficient to auto-check these dates to administer the medications for you.

If you do not need time slots, delete the text from those boxes and click "Save" when finished updating each medication.

Preview of medication once you click save.

MEDS TAKEN (Top)

You can document "Meds Taken" within the service note once the meds are setup. Click on the "Meds Taken" link.

Enter the required information and click "Save" when finished.

DIAGNOSES (Top)

On the Patient History and Diagnoses Section, you will enter your diagnoses codes by typing in either the numerical code (including the ".") or you can also search by enter text. Once you have entered the information, click enter to search.

Make sure you enter the severity

As well as the exacerbation date

You will be able to determine the Clinical Group based on patient’s principal diagnosis

You have the option to enter more than just the top 6 diagnoses on the "Additional Diagnosis Codes" section.

You can also rearrange the diagnoses by clicking on the "Swap Diagnoses" link.

To rearrange the diagnoses, just renumber the diagnoses into the order you would like for them to appear and save.

You can also edit a secondary diagnosis by Selecting an existing diagnosis that appears in locator “13. Other pertinent Diagnosis” (diagnosis and date populate the entry fields for this diagnosis) and change the diagnosis and/or date as necessary. Then select the Update button.

Secondary Diagnosis Coding Changes For Hospice

You can now identify if a secondary diagnosis code is “comorbid/secondary” and/or “related to terminality”. Additionally, you can now make changes to a secondary diagnosis without having to delete and re-enter information on the Care Plan, IDT or the Hospice Discharge Summary form.

To add secondary diagnosis information to one of the documents, use the following path: Patients > Patient Encounters > Find/Select a Patient > Orders tab > Select the “Edit” icon for the form that you want to update (Care Plan, IDT or Hospice Discharge Summary). Search and select a diagnosis in section “13. Other pertinent Diagnosis”. Enter a date for onset/exacerbation and check the box for “Comorbid/Secondary” as necessary.

The Comorbid/Secondary Dx is indicated with "CO".

Check the box for “Related to Terminality” as necessary

The "Related to Terminality" dx is indicated by "RT".

In Non-Oasis service notes, you have the ability to add up to 25 diagnoses.

VITAL SIGNS (Top)

Data you enter in the “Vital Signs” section of a Service Note will now be compared to the vital sign parameters you established in the Patient Encounter Clinical Tab. If the vital sign parameters do not exist in the Patient Encounter file, your responses will be compared to the parameters established for the Service Note item (appears in the background of the Service Note item). If no parameters are set up for either the Patient Encounter or the Service Note item, no alert displays.

If a specific vital sign you documented is outside the acceptable range, an error icon displays next to the item. Hover over this error icon to see what the acceptable parameters are for the specific vital sign.

NOTE: Vital Signs information must have a “matching code” as part of the Service Note item. You will need to contact our Careficient support team to have your Service Notes set up to use the alerts feature.

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

M1800 COMMENT FIELDS (Top)

“Comments” text boxes are available for OASIS assessment questions that appear within the OASIS integrated service notes as follows:

TP 1 Start of Care-Further Visits Planned o 1845–ToiletingHygiene
- 1850 - Transferring
- 1860 - Ambulation/Locomotion
TP3 – Resumption of care (after inpatient stay)
- 1845 - ToiletingHygiene
- 1850 - Transferring
- 1860 - Ambulation/Locomotion
TP4 – Recertification (follow-up) reassessment
- 1850 - Transferring
- 1860 - Ambulation/Locomotion
TP5 – Other follow-up
- 1850 - Transferring
- 1860 - Ambulation/Locomotion
TP9 Discharge from Agency
- 1845 - Toileting/Hygiene
- 1850 - Transferring
- 1860–Ambulation/Locomotion

The text boxes allow the clinician to further describe the patient’s condition related to the responses to the ADL/IADL questions. Detail documentation in these 3 areas will help you to satisfy a clinical survey or an ADR. Additionally, you will be able to create an “other” interim order that you can use that could help you satisfy expected documentation for the Face-To- Face regulation. These text boxes also appear within the actual OASIS record. If the associate has privileges to "approve oasis", they must check the box to create the “Other” interim order prior to approving the OASIS integrated service note.

If they do not have this privilege, the associate with the Approve/Lock permissions must check the box to create the “Other” interim order prior to approving/locking the OASIS record from the Orders tab, OASIS section. The “Other” interim order feature is not available for TP9 – Discharge from Agency.

NOTE: Once you approve an OASIS record, you will no longer be able to create the “Other” interim order. You can select to print the form and save it in a PDF file, which will allow you to copy/paste into an “Other” interim order that you can add in the Orders section.

NOTE: For Careficient Agency Administrators, to use this functionality you must activate the Agency rule that reads: “Service Note – Approve Oasis”. The clinicians must have the “Edit Patient” security permission.