POC Training - Chart Documentation

1. Pull up the patient from the Select Patient screen (Main Menu). 

2. From Barnestorm Office click the Patient Histories button from the Main Menu. A menu will pop up right underneath that, and from there you will select ICD History.

• From Point of Care select the ICD History button or use the Current ICD > Edit ICDs screen within a visit assessment. 

3. Under the ICD Effective Dates label, click on the drop down arrow to select the from date for the new ICD codes. Or type in the date that you desire. This will be the date of the visit to your patient, when you determined that the condition of the patient has changed. This occurs most frequently on a resumption of care after an inpatient stay.

Note: If you are entering ICD codes for the first time, be sure the From date is at least on or before the patient's admit date.  This could cause billing issues.

4. Click the New Date button. This will populate the date selected into the list of ICD From Date in the panel below.  If a previous date already exist then the most recent ICD codes will copy into the new ICD From Date.

Step 2:  Add/Change/Remove Diagnosis Code for Selected Effective Date:

5.  To add diagnosis:  Select a clinical grouping category above the code search before searching for the ICD code.  This will filter only PDGM codes for you to choose from.  You can still search by number of word as usual when seeking a code after you pick the category.  Select the appropriate code. 

6. A warning message will appear if the primary ICD code is not assigned to a clinical group. Note that if a claim requires a HIPPS code then the primary ICD must be assigned to a clinical group.

7. Select the onset date, O/E, and severity level.  (The Onset Date cannot be dated after the ICD From Date.) Click Save button after each entry.  Proceed with next code entry.

8. The Clinical and Comorbidity group will show up in the ICD list at the bottom of the screen.  You may need to maximize your screen to see the Comorbidity column, or you can size the columns to fit your screen. Yellow = assigned to a clinical grouping; Green = is scored in a comorbidity group; White = not assigned to a group.

9. When finished entering all codes click on the red Save All Changes button and then Exit. 

• Pull up the patient from the Select Patient screen (Main Menu). 
• From Barnestorm Office click the Patient Histories button from the Main Menu. A menu will pop up right underneath that, and from there you will select ICD History.  From Point of Care select the ICD History button.

• A list of the ICD History for the selected patient is displayed on the left. Select the date for which you would like to edit the code. The ICD codes, for the date selected, will be displayed at bottom of the screen.
• Click one of the codes to edit it. The code will be highlighted after you click it.
• Edit the code, onset, O/E, and/or severity as needed.
• Click the Save button. Continue with editing of codes, as needed.
• Click the red Save All Changes button when finished.  Then click on Exit. 

Change the order of codes

You can change the order one of two ways:

ReOrder

• Click the Reorder button to change the order of the ICD codes that are listed. A window will pop up with the codes listed on the left.
• Click the most important ICD code from the list on the left. It will be move to the list on the right at the top as the most important.
• Click the second most important code next and it will move to the right, under the first code.
• After you have reordered all of the ICD Codes, click the Save Changes button.

Move Up / Move Down

• From the list of ICD codes, click on a code and then click on Move Up or Move Down to move it to the position you want it at.
• After you have reordered the ICD Codes, click on the red Save button. 

From Barnestorm Office click the Patient Histories button from the Main Menu. A menu will pop up right underneath that, and from there you will select Surgery History.  From Barnestorm POC you will click on Surgery History. Select the patient from the Select Patient screen.

Add Surgery History

• For the Surgery Date, click on the drop-down arrow to select the date for the new surgery. Or type in the date that you desire. This will be the date of the visit to your patient, when you determined that the condition of the patient has changed. This occurs most frequently on a resumption of care after an inpatient stay.
• Enter the surgery by number if you know it, or you can type a word into the description and you will get a list of all codes that contain that word.
• Click the Save button and the surgery code should appear in the grid of surgery codes. 
• As needed, click on Add a New Surgery Code to add more surgeries.  Repeat steps 4 - 7 to add another code. 

Edit Surgery History

• A list of the Surgery History for the selected patient is displayed. Select the surgery code for which you would like to edit. 
• The surgery code will appear at the top of the screen after you click it.
• Modify the information and click on the Save button.  
• Note that you cannot change a date for a surgery already listed.  You must first delete the code and re-enter it with the appropriate date. 

• Select a patient on the first Barnestorm screen by typing in either the patient’s chart number or the first 3 letters of their last or first name.
• From Barnestorm Office click the Patient Histories button from the Main Menu. A menu will pop up right underneath that, and from there you will select Medicine History. From Barnestorm POC you will click on Med History. 
• Click the New button from left panel.
• The Add / Edit Medicine Code window will pop up, allowing you to enter a medicine and the related information.
• Enter the medicine by typing a few letters of the medicine into the Medicine box and you will get a list of all medicines that contain those letters.
• Select the medicine you want by clicking on it.
• Next, enter the Effective Date to indicate when the medication has or will start.
• Office users will need to change the employee to the appropriate ordering staff member. 
• By default, the primary physician is filled in, but you may change the doctor, as needed.
• Type in a Dose / Frequency / Route. You must type this information—the medication cannot be saved without it.

• Optional: Type in what the medication is treating in the Treatment area.
• Optional: Under Schedule, click button(s) as needed to indicate when the patient should take this medication.
• Click the Save and Exit or Save, then prepare for another medicine button. The window will close or refresh the screen for another new medicine entry.
• The panel will display the list of medicines for that patient.

You can also use the Medication Builder to enter medication information.  This can help ensure that each required section of the medication is entered. 

• When you click on New Medicine, New Dose/Freq/Router or Edit Entry, check the box “Show/Hide Med Builder”.  
• Enter and select the required dose, freq and route information.
  

• All other boxes are optional.
• There’s an option to translate the abbreviations to words or to make all letters uppercase.  
• Click on Build Dose/Freq/Rte button. 
• An error message will appear if any required boxes were left out.
• The information will show up in a Dose/Freq/Route format. 
• Save the medication when finished.  

Note: If your agency wants the Medication Builder screen to show up as default each time, someone with a high security level can go into Codes > Security > Global Settings > Patient Histories.  Make the On Med History, Required the Dose/Freq/Route Builder Panel equal True.  This will change the default for all Barnestorm users.

This will show you how to update the dose and/or frequency for a medicine already in listed in a patient's med history. 

Note: Do not use the Edit button unless you are correcting an entry that was keyed by mistake. 

• Click one of the medicines to add a new entry for it. The medicine will be highlighted after you click it.
• Click the Add button from the right panel. The Add / Edit Medicine Code window will pop up.
• (Optional) Click the C to indicate that this is a medicine change.
• Edit the dose, schedule, or other information as needed.
• Click the Save and Exit button. The window will close.

For a short-term medication, like an antibiotic, you can add the start and end date for the medication all at once so you don't have to go back into the system on the date it ends. Here's how:

• Add the medication into Med History like you would normally add the medication. Set the Effective Date to be the date that the medication started. Enter the dosage/frequency/route as noted per the prescription.
• Save and Exit. The medication should be selected.
• Click the Add button from the right panel. Change the Effective Date to be the date that the medication will end (this is the first day that the medication will NOT be taken; the day after the course is complete). This date can be in the future.
• Click the Discontinue (Stop Med) button.
• The medication should now have two listings: one for the start date, and a STOP for the end date. You've entered everything for this med and will not need to revisit it later.

Edit Medicine(s) for a Patient:

Use the Edit button to make changes to the medicine if you made an error when you entered it. 

• Select the medicine then the correct Dose/Freq/Route and click on the Edit button. The Add / Edit Medicine Code screen will appear.
• Edit the medicine then click on Save and Exit button.

**In POC:  Only the employee who originally entered the medication can edit the entry.  If a different employee needs to change a medication, click the Add button to add a new entry.  

**In Office:  Any employee who has permission to edit the screen can change it.

Discontinue Medicine(s) for a Patient:

Use this process when a medication is being discontinued for the patient.

• Select the medication that needs to be discontinued. 

You have two options:

A)  If today is the date to discontinue, click the Stop button to automatically discontinue effective today. 

B)  Click the Add button.

Change the date to the date the medicine was or will be stopped and click on Discontinue.

The window will close. Note that the medicine will be gone from the list if the effective stop date is before today.

To see all medicines, even discontinued ones, click the Show All Meds button.

If you click on a discontinued medicine, it will list the discontinued date along with the word “STOP”.

Delete Medicine(s) for a Patient:

• Highlight the medicine that needs to be deleted
• Select Edit Incorrect Entry tab
• Select Delete
• If you are sure you want to delete the medicine, click Yes.

The messaging system in Barnestorm is similar to inter-office email.  The intended purpose is to aid in the communication of information between employees that are logged into the Barnestorm system.  Message recipients are notified that they have a new message by a pop-up in the lower right-hand corner of their screen and also, a red banner notification across the Main Menu screen.  Messaging will only work when employees are actually logged into the Barnestorm system.  Point of Care users must synchronize before receiving any new messages.  Messaging will also allow you to choose if you want to send the message via text message or email.  See the attached link for details.  
 

The emergency plan screen in Barnestorm meets 2018 CoP specifications and can be located in Barnestorm Office on the Referral, from Point of Care on the Main Menu, and within a SOC, ROC or Recert assessment type. 

There is not a save button on these screens because the information will automatically save if you're going from screen to screen within the referral. However, if you only update the Emergency Plan, click the Save All Patient Data button before you move to the next patient. 

The following information can be documented:

• Risk level
• Acuity
• Priority level: level 1 contact within 24 hours, level 2 within 24-48, level 3 within 48-72 hours
• Evacuation plan: to remain in the home, evacuate the home and assisted by agency, emergency officials or patient contact (a contact drop down list will appear when checked) 
• Special Needs
• Other Needs: Text box to type in notes or use the text item box to insert text

The print preview will add the patient’s name, chart number, date of birth, address and phone number, emergency contact person (marked from the Contact tab of the Referral), emergency number and address. 

LACE Index Tool helps to identify possible urgent readmission or death within 30 days of discharge from hospital.  

The following information is an except from https://www.besler.com/lace-risk-score/ 

• “L” stands for the length of stay of the index admission.
• “A” stands for the acuity of the admission. Specifically, if the patient is admitted through the Emergency Department vs. an elective admission.
• “C” stands for co-morbidities, incorporating the Charlson Co-Morbidity Index.
• “E” stands for the number of Emergency Department visits within the last 6 months.

LACE scores range from 1-19 and as mentioned above predict the rate of readmission or death within thirty days of discharge. Below is an example of how to calculate the LACE index. A score of 0 – 4 = Low; 5 – 9 = Moderate; and a score of ≥ 10 = High risk of readmission.

The Fall History screen will show the documentation of fall entries/post falls for a selected patient.  Point of Care will allow the clinician to mark a fall as "Fall Precautions Retaught This Visit".   Please note that the screen within the assessment is named Post Fall and will have a main menu that shows the list of falls.

 

From Barnestorm Office pull up the patient and click the Patient Histories tab then select the Fall History tab. 

From Barnestorm Point of Care pull up the patient and click on Fall History from the Main Menu or within a visit assessment.

 

The main screen of the Fall History will show the date of the fall, observed by, location, and if the fall precautions was retaught it will show the name and date of the assessment.  

NOTE: If you are viewing this screen outside of a visit assessment you will see a button labeled "Pull Post Fall Assessments".  This will pull previous post fall entries into the Fall History screen. 

Fall History > Main Menu

Add Fall

• Click the Add Fall Button.
• Enter the Date of the fall.  Select the drop-down calendar to select a date, as needed.
• Check the box Alone at time of fall or Fall was observed.
• If Alone at time of fall was checked then Observed by will become grey and "Patient was alone" will show up.
• Otherwise, key in the name of the person who observed the fall.
• Enter the Location, Reason and Safety device they were using.
• Document the Surroundings by checking each box that applies to the scenario or type in the Other box a description.
• Document the Healthcare status by checking each box that applies to the patient or type in the Other box.
• If the patient and/or caregiver needs retaught the fall precautions, check Reteach Fall Precautions.
• Use the Interpretation to box to type notes regarding the fall. 
• Click on Save.

Edit Fall

• Select the fall from the main menu of the Fall History screen.
• Click the Edit Fall button.
• Modify the documentation needed and click on Save.

Delete a Fall

• Select the fall from the main menu of the Fall History screen.
• Click the Remove Fall button.
• A message will appear asking if you are sure you want to remove the fall.  Click on Yes to remove or No to cancel.

*This can also be done from within the Edit Fall screen.

Print Falls

• To print an individual fall, click the fall from the main screen.
• Click the Print Fall button.
• From the preview click the printer icon to send to the printer.
• Click on Close.
• You can also print the fall from the Edit Fall screen.
• To print a running list of falls, click the Print All Falls from the main menu.
• From the preview click the printer icon to send to the printer.
• Click on Close.

Document Re-teaching of the Fall

The following option can only be done from a visit assessment.  You will be able to "reteach"  fall precautions more than once per fall. The history of fall precautions is listed within the Edit Fall, which shows who retaught and when. 

• From Point of Care visit assessment, locate and select the Post Fall screen.  If a fall entry has been marked as needing retaught, then it should show up under the Required section of the note.
• Select the fall entry you need to re-educate the patient on.
• Click on Edit Fall.
• Check the box for Fall Precautions Retaught This Visit.
• Click on Save.
• The preview of the visit assessment will show the fall entry information, along with the phrase "Fall Precautions Retaught This Visit". 

Fall History Main Menu in Point of Care

Fall History > Edit Fall

NOTE:  The Post Fall entry will only print onto the assessment if "Fall Precautions Retaught" box is checked with the retaught date, during the documented visit.  Example:  You are documenting visit for 05/30/24 where you have completed re-teaching of the fall precautions during your visit.  Your screen should look like the picture below.  If reteaching was done on 05-29-24, it would be documented during that visit:  05-29-24.  To obtain a listing/history of patient falls, see 2nd paragraph above.

• Select the patient that needs the facility and transfer OASIS created.
• Click on Transfer button from the Main Menu.
• Click on the Edit Facility History button.
• Click on the New button.
• Enter the name of the facility, dates of stay, and reason why admitted.
• Click on Save and then click on the red X in upper, right corner.
• Enter the MO090 date, MO903 date, MO906 date and click on Create Assessment Type 06 or Create Assessment Type 07.
• Continue by answering the rest of the OASIS questions.
• After all are answered click on Mark OASIS as Completed, Not Locked or Lock OASIS.

Create Verbal Order Video: Verbal Order - YouTube

Care Coordination Note Video: Creating a Care Coordination Note (CCN) Video - YouTube

• Click the Care Coordination button on the Main Menu.
• To create a new care coordination note for this patient, click the New button in the upper left corner.
• IMPORTANT NOTE: If the NEW button is RED , you have NOT clicked it and anything you add will NOT BE SAVED! 
• The NEW button will be GREEN if you have clicked it to start a new care coordination note.

• The employee who is logged into Barnestorm in will show up by default. If you have permission can change the employee someone else.
• The When area needs the date and time that the communication (call, conversation, letter, fax) occurred. Also fill in how long it took in the blank that allows you to fill in minutes (optional).
• Select either the To or From, depending on who made the call (or sent the fax, etc.) Example, if someone contacted you, click the From box. 
• (Optional) Click the Select From/To button. This will pull up a list of the people associated with this patient, including the doctors, emergency contact, caregiver, nurse, and any person associated with this patient. 
• You can select a person from the list to insert their name into this field. You can also type in the name in the box beside the To and From boxes.
• Next, click on the Topic button. Select a topic from the list that appears. If you need to specify a different topic, click the Other item and the text box will become activated. You may type the topic into this area.  
• The Status area indicates whether the status of this note is Open (meaning unresolved or uncompleted) or Finished (meaning resolved or completed).
• To include this care coordination note on the patient’s 60 day summary, check the Add to 60 Day Summary box near the top (beside the When items).

• Next, add the information that was communicated in the box called Discussion. 
• (Optional and based on each agency) Using the Text Item feature will allow you to insert common phrases used at your agency. If you need to select more than one of these orders, you can click the box beside Multi-Select. Then, click as many orders as you need.  
• When you finish selecting the text, click the Insert Select Text button. 
• The list will close and you will see that the text items you selected appeared in the Discussion panel. 
• You may edit, add and change the text in the Discussion panel as needed. 
• To copy other staff members on this care coordination note, click the cc:Staff button to the left of the Discussion panel. All staff involved will be able to retrieve the note. 
• If you only want select staff to retrieve the note then click on cc: Select. A list of all employees will appear for you to select from. A cc note will appear at the bottom of the Discussion panel, and other staff members will be able to retrieve the notes (instructions for this are available under “Receive Care Coordination Notes Copied to You”).

• When you have completed the care coordination note, you may print a copy of it by clicking the Print This CCN button the bottom of the screen.  You also have the option of printing the note in landscape, add the patient’s date of birth, or print large font. 
  A print preview window will appear, and you can click the printer icon in the upper left corner to print the page. Click the X in the upper right corner to close the print preview and return to the care coordination screen.
• Click the Save button in the bottom right.  Be sure to mark the note as finished when it is complete and save the note again.

* Note: you can use digital or the employee's signature.  See the related article below on how to change options. 

The purpose of the Copy to Comments button is to add documentation to the assessment without having to re-enter the orders.  This can save time and eliminate entry errors.  It takes information from the most recent verbal order and places it in the assessment.  You can use this feature with the IV, Labs, Feeding and Supplies screen.  Below is an example on how to use it.

Create a verbal order by select the appropriate Type from the drop-down list (IV for this example).  After the order information is entered and saved, it will be available in the assessment to insert into the documentation. 

When you’re on the IV screen in the assessment, you’ll notice the most recent IV order text at the bottom of the screen. 

 

When you click on the button Copy to Comments, the text from the verbal order will appear in the white box, which will show up on the printed assessment.