HH Care Plan (Not Diagnosis-Based)

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

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

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. 

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. 


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. 


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.