You can add a new care plan from the Main Menu in Office or Point-of-care or from the Visits/Assessments.

• Click the Get Started button.

• Make the From and Thru dates match the 485 60-day episode. 
• Set the Short term and Long term goals dates. Clicking the number of weeks next to the date will help automatically adjust the dates.
• Rehab Potential and Target:  Defining one will automatically update the other accordingly. These are used to monitor the progress after each assessment. 

How to pull Interventions / Short Term Goals / Long Term Goals / Outcomes / DC Plans

• The interventions and corresponding goals are based on the Problem you have selected. 
• For nursing, there are several problems to choose from, the SN Observation/Assessment problem is selected by default. 
• For therapy, there's only one problem, Observation/Assessment. 
• You'll go through each tab and check appropriate indicators for the plan (Interventions, Short Term Goals, Long Term Goals, Outcomes, and DC Plans).
• For nursing, go back to the Problems tab and select the next topic to select indicators for each tab. Repeat until all desired problems have been covered.
• As you add different problems you'll see your list starts to build for each tab.
• Note: Some indicators may appear duplicate when adding more problems as some may have the same options. 
• Each tab has a field at the bottom to add a custom item. Enter the description and then click on the 'Add' button. 
• Click on Save Care Plan once you have added all problems.

This will need done from the Main Menu of Office or Point-of-Care and will only be active during the 5-day recert window or later. 

• Click the 'New Plan' button near the top of the screen.
• The dates will automatically advance to the next episode. 
• You can toggle through the episode periods by clicking Previous and Next Plan. 
• Be sure you have the correct/new episode selected and then click the Edit Care Plan button. 
• Run through each tab to update the information for the new episode.
• Click on 'Save Care Plan' when finished.

If you need to change interventions or goals during a visit, keep in mind that this will require a change order, and you can make the changes by clicking the Edit button from the Visits/Assessments > Care Plans screen.

From the Main Menu, select the correct discipline and verify you have the correct episode dates selected before you click the Edit Care Plan button.

You can start a Care Plan assessment: 

From the Main Menu > Care Plans by clicking 'New SN Assessment' or 

Within the Visits/Assessment on the Care Plans tab. 

Interventions

On the Interventions tab, all of the interventions on the plan are available. You can click the All Interventions Completed button to mark them all as checked at once, or you can check them off one-by-one. You may also type comments under any where you'd like to comment.

You'll also have marker that shows you how many have been completed.

Short Term / Long Term Goals

You can indicate the progress the patient has achieved as of this visit toward each goal. You can also type a comment. The Use Previous Values button at the top will pull the percentages from the previous visit so you can use them as a guideline toward assessing where the patient is now in comparison.

Progress history within the assessment

You will see the most recent value documented with the assessment date next to each goal. You can click the history icon to view the past values and dates. 

Outcomes and DC Plans

Go through to mark which have been met (Outcomes) and reviewed (DCPlans). 

Care Goals

Work your way through documenting each section. You can use the Text Item feature to insert predefined phrases. 

You also have a way to view the history of each assessment using the history/clock icon. This will also allow you to select a phrase previously used to insert the text into the current assessment. 

Patient Communications

Patient Communication allows you to document various aspects of patient communication specified by Conditions of Participation, such as instructions.

The Instructions for Patient has a printer icon next to it so that you can print out for the patient. 

Progress

The Progress tab will show you the target and progress noted for each assessment. The target is purple and the progress is green. The bottom will also show the progress rating of each assessment. 

Each dot represents a visit, ending with the most recent visit. 

Discipline and PRN Orders will pull from Verbal Orders when the Discipline type is selected. The order must be dated between the care plans From and Thru date. PRN orders must have PRN in the description.