POC Training - Visits/Assessments

From Barnestorm Point of Care, you can start an assessment a couple of different ways. 

Starting the Visits/Assessments Video: Starting the Visit/Assessment - YouTube

Edit Visits/Assessments Video: Edit Visit Assessment - YouTube

You can edit the assessment the same way you started the assessment.  Instead of using the New button you will use the Edit button. 

If the visit is locked then you will need to unlock it first from the Visits/Assessment screen.

You will need to have an appropriate member of an office staff unlock the visit, if you do not have permission.  You will need to complete a sync to get the update.

From Barnestorm POC

Vital Signs Video: Vital Signs - YouTube 

To add vital signs parameters for an individual patient in POC, you'll need to create a vital signs order.

Pain Assessment Video (Start at 11:56 and end at 17:56): Pain Assessment in Visits/Assessments

Point of Care > Visits/Assessments > Pain screen. This screen has several tabs that run across the top of the screen. Some questions may differ depending on the payer type. 

Main

Point of Care > Visits/Assessment > Wound Assess. This screen may show up under Optional.  Once there is an active wound documented, the Wound Assess will show up under Required.

Wound Assess (Old) Video: Wound Assess (Old Screen) - YouTube

Point of Care > Visits/Assessments > Wound Assess. This screen may show up under Optional. Once there is an active wound documented, the Wound Assess will show up under Required. 

You will have the option to Select an existing Wound or create a New Wound. 

Select a Wound: This will show you a list of all wounds, the last time they were assessed or the date it was marked as healed. 

After selecting the wound you need to assess, it will pull up the wound screen with the description and location filled in.  The wound measurement may copy forward if your agency has that feature turned on. 

New Wound: To create a new assessment for a wound, click the New Wound button. You will notice that the wound has been assigned a number at the top of the screen.  If this is the first wound for the patient, this will show:  "Assessment for Wound #0001."

Documenting the Assessment

Select the type of wound by clicking on one of the type options. If the type is not listed, you can enter it in the text box. You must specify wound type.

If the wound is a pressure wound, you may select the stage of the wound. If you do not remember the stages, click the Show Stages button. The stages of the wounds will be displayed. After you figure out which one you require, click the Hide Stages button.

To specify the location of the wound, you can either (1) type in a location, or (2) click on the * button beside the location box . The screen below will pop up when you click the * button.

Select either Anterior or Posterior. Then, select a location on the body that corresponds to the General Location of the wound. Click on the image to select the area. After the general location has been selected, you can choose a specific location by using the pull-down tab. Click the OK button. The wound location will be filled in.

NOTE:   If the location is not filled in, the wound entry will NOT be saved.  At this point you have filled in all the required fields for this wound. The rest of the fields are optional.

You will notice that the description at the top of the screen is filled in with the options that you have selected.

There are some optional buttons to help you quickly enter more information about the wound. Click on any button that matches information you wish to enter.

The intent of these screens is to save time by clicking on buttons instead of typing. But, if you wish to type in a description of the wound, do so, and then click the OK button. As you click on the buttons, those descriptions will be highlighted in yellow, and appear inside the description box.  Click OK when you are done.  You will be taken back to the wound main screen.

You can select a Status for the wound as well.  Located at the bottom of the screen.

Additional Comments can also be entered.  Located at the bottom of the screen.

Link Wound to Order Video: Wound Orders Linked To Assessment - YouTube

Each time you assess a wound in your visit note you can have the wound care order automatically show up on the assessment.  The first thing that will need to happen is to have a wound entered in the note and assigned to a number.  Next, you have two different ways you can start a wound order; straight from the Wound Assess screen in the assessment or from the Verbal Order screen.  After you create the wound order and pull up the wound in your assessment, it will show the wound care orders in past tense.   Here are the options below:

Straight from the Wound Assess Screen:

• Start a new wound or pull up an existing wound from Visit / Assessment > Wound Assess screen.
• After assessing and documenting the information for the wound; enter the wound order information in the Comments box at the bottom of the screen.
• Click on the button “Add Wound Order”.  Or, if you are updating the wound order information then the button will say “Update Wound Order”.
• A message will appear stating that a wound order has been created and can be found in the Orders screen > Show Orders – VO Not Needed. If you need to create an order follow the next steps.
• Press the Pause button from the assessment and click on Orders.  Click on the button Show Orders – VO Not Needed. From here you can create a verbal order.
• The next time you assess this wound, the wound orders will show up in the Comments section.  

Create Wound Order from the Order Screen:

• From the assessment create a new wound as needed in the wound assess screen.
• Click on the Pause button from the assessment.
• Click on the Orders button and then enter your Barnestorm password.
• Start to create a verbal order as usual.
• From the Type drop-down list click on Wound.
• From the order builder screen, select the wound you want to assign the orders to.  The wound care orders will not show up on the assessment if you skip this step.
• Click on Create Order.
• This will pull the previous wound documentation.  You can erase all of this data or modify it.
• Enter the wound care orders and then click on Save.
• From here you can turn it into a Verbal Order or No VO Needed – or you can leave it as a pending order until it is complete. 
• Click on Resume from bottom-left to go back to the assessment.
• Select that wound again in the Wound Assess screen.  You’ll notice at the bottom of the page the wound care orders will appear in past tense form.

·         In verbal order screen like this:  CLEANSE WITH SOAP AND WATER. PAT DRY. APPLY DUODERM.

·         Shows up in note as: CLEANSED WITH SOAP AND WATER. PATTED DRY. APPLIED DUODERM.

Example from the Visit / Assessment > Wound Assess screen when entering wound orders for the first time.

Example from the Visit / Assessment > Wound Assess screen when assessing the wound after wound order has already been entered.  Notice it shows up in past tense. 

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.

Review Meds in Assessment Video: Scheduled Visit Video - YouTube

** Parts of the video will look outdated but overall works the same. 

Pull up a Review Meds screen from a Point of Care assessment.  When you first open this screen, you will see several tabs at the top of the page.  Select a tab to modify the information.

 

Review

This feature is used to verify which medications were checked in the home.  If there are only a few medications to check, you can check the Mark All Meds as Dose Freq Route Verified.  This will check the Verified Dose Freq Route column for each medication listed.  If the patient has a long list of medications, then you can select one med at a time as you check them. 

If you want the meds to show up on the printed assessment, then check the box Print All Reviewed Meds or check the box for Print to select specific meds. If this is the first time using this screen for the patient, then the New/Chg and Last Date Verified will be blank.  The New/Chg column will show the date that the medication was added or changed.  If the med has [] next to it then the med was added on the date shown.  If it has [C] then the date shown is the date of the last changed Dose Freq Route.   Use the Edit Med History button to make changes to the medications. 

Rules for the New/Chg date to show up on the assessment Preview/Print: If the medication was added or changed two days ago and up to five days after the note was started AND the effective date is on or before the visit assessment date. 

Teaching All

This screen is used to document the general teaching information; including: Person(s) taught, Barriers to learning, and Goals.

 

Teaching Detail

You can document how the medication teachings were given.  Check the Taught By boxes that apply and select an Evaluation option.  You can click on the Mark All Meds as Taught or click on each specific med to apply the Taught By and Evaluation.  Repeat the steps by changing the Taught By and Evaluation if other medications were taught differently. 

The How Taught will show a V for Verbal, H for Handout, D for Demonstration.   Click on the Info box to view the medication information. 

Click anywhere on the medication information to return to the Teaching Detail screen. 

To clear a set of answers on a medication that was added by mistake; first uncheck all answers from the questions at the top of the screen.  Then click the medication that you want to clear out.  Note: to clear answers the Who was taught and Evaluation you will need to right click the answers. 

Pill Box

This screen is intended to help you fill the patient's pillbox. After the screen is set up, it shows the number of pills that should be in each section of the pill box. To view the medication name(s), move the cursor over the number.  The pill box only needs to be set up once and then changed when medications change.

If the Schedule section of the Med History screen is complete, then this screen will show you when each medication is taken (breakfast, lunch, supper, bedtime).  If the schedule has not been filled in yet, you can check the appropriate boxes for each medication on the Pill Box screen.

 

Click on the Import All Meds to PillBox per Schedule button.  This will perform two tasks:

1) Any schedule that was checked (breakfast, lunch, supper, bedtime) from this screen will be imported into the Med History > Schedule screen. 
2)  The Sunday – Saturday pill box setup will fill in the number of meds each day / scheduled time has assigned. 

PillBox Notes
This screen allows you to document miscellaneous information about the pillbox setup.

 

Insulin Syr

If the medication history has an insulin med then you can use this screen to document any prefilled syringes. 

 

Match ICDs

Use this screen to link each ICD code to a medication.  Click the ICD code, then click the corresponding medication.   To use an indicator, check the box for Pain, Supplement or Other and then click the medication.  If Other is selected, you can type in a description before selecting the medication.  

Click SAVE before leaving the screen.  When you click SAVE, the ICD description or indicator will save in the Treatment section of that medication's Med History. 
 

Meds/PillBox Setup

You only need to use this screen if the standard pillbox that is already shown on the Pill Box screen does NOT look like the pill box the patient has.

Use this screen to create the pillbox layout.  You can use our standard layout or create your own by entering the headings separated by commas, then click on Create Pillbox.  If you make changes, click on Save This Pillbox Setup Info. This needs to be done only once to set up the pill box. It will not be repeated on subsequent visits. The only time this will be used after the pill box is set up is if the patient gets a new pill box.

You can also document who the meds are setup and administered by.  This information is also saved in the Referral > Misc screen.  

Create 485 from Assessment Video: Build 485 from Visits/Assessments - YouTube

Under normal circumstances, you can ONLY create a 485 from a Start of Care assessment or a Recertification assessment. (This allows the assessment information to be fully utilized, and also eliminates re-typing.) Under certain circumstances you can create a 485 from a Resumption of Care (ROC), but only when the ROC is within 5 days of the Recertification.  In those cases, the Recert is not required.  After the visit assessment is complete, go to the Finish screen and Set the End Time. At that point the Build 485 Document tab will activate. Click on the Build 485 Document button. A small screen will appear with Certification Dates.  (Pictured Below)  

1. Verify that the From/Thru date is correct.  NOTE: For SOC, if the From Date is incorrect on this screen, the date of admission will need to be corrected in the Referral first.
2. Verify the "Certification Period is for" is correct.  
3. You have the option to Apply Verbal SOC date.  Check that box and enter date, whenever applicable. 
4. Check the box beside Copy Aide Orders, whenever applicable.
5. Click on Create. A message will appear saying the 485 Document has been created. 
6. Click on Preview to view what the printed document would look like and to verify the data entry of information. 

IMPORTANT NOTE:  If you need to go back into the visit assessment to make changes to 485 information, be sure to Rebuild the 485 from the Finish screen. This will copy the changed information to the 485.  Repeat the steps above. Instead of Create (Step e), the button will say Rebuild.  (Pictured Below)  When you click on Rebuild a message will pop up asking if you want to replace the information on the 485.  Click on Yes.  

Create OASIS from Visit Video: Build OASIS from the Assessment - YouTube

You can ONLY create an OASIS from a Start of Care, Recertification, Resumption, Special Followup or Discharge assessment type. The first step before creating an OASIS is to complete the assessment entirely.  The OASIS answers that are entered into your assessment will be pulled by a single click and created into a separate OASIS document.  From the Finish screen complete the Set Start Time and Set End Time.  At this point the Build OASIS tab should become active. Click on the Build OASIS Document button (NOTE:  If payer is not selected, on start screen, this tab will not activate). You will need to answer the M2200, M0110 and M0090 questions and then click on the Create button.

A message will appear saying the OASIS Document has been created.  It will either notify you that there are no errors found or it will list the OASIS questions with issues.  

If the OASIS was created without any issues you have the options to preview and print the OASIS.  The OASIS cannot be locked from this screen; you must use the OASIS screen to Validate and Lock.  Exit out of the Build OASIS screen.  

If there were errors and questions need to be fixed or answered, exit the Build OASIS screen and click on the red eclamation box located in the upper, left corner of the screen, above the Required fields.  A list of questions that need attention will appear.  Click on the question and you will be directed to the appropriate screen.  Make corrections to all answers and then go back to the Finish screen.  You will need to rebuild the OASIS so that the assessment and OASIS match.  Click the Build OASIS button and then click on the Rebuild button.  From there you will either see that there are no errors or you may need to continue correcting answers.  If more corrections are needed, repeat the steps above.  

**IMPORTANT Note:  If you go back into the visit assessment to make changes to OASIS questions, be sure to Rebuild the OASIS from the Finish screen.

This will copy the changed answers to the OASIS. To rebuild, follow same steps from above.  Instead of clicking on Create, you will click on Rebuild.

Review Meds in Assessment Video: Scheduled Visit Video - YouTube

** Parts of the video will look outdated but overall works the same. 

Pull up a Review Meds screen from a Point of Care assessment.  When you first open this screen, you will see several tabs at the top of the page.  Select a tab to modify the information.

 

Review

This feature is used to verify which medications were checked in the home.  If there are only a few medications to check, you can check the Mark All Meds as Dose Freq Route Verified.  This will check the Verified Dose Freq Route column for each medication listed.  If the patient has a long list of medications, then you can select one med at a time as you check them. 

If you want the meds to show up on the printed assessment, then check the box Print All Reviewed Meds or check the box for Print to select specific meds. If this is the first time using this screen for the patient, then the New/Chg and Last Date Verified will be blank.  The New/Chg column will show the date that the medication was added or changed.  If the med has [] next to it then the med was added on the date shown.  If it has [C] then the date shown is the date of the last changed Dose Freq Route.   Use the Edit Med History button to make changes to the medications. 

Rules for the New/Chg date to show up on the assessment Preview/Print: If the medication was added or changed two days ago and up to five days after the note was started AND the effective date is on or before the visit assessment date. 

Teaching All

This screen is used to document the general teaching information; including: Person(s) taught, Barriers to learning, and Goals.

 

Teaching Detail

You can document how the medication teachings were given.  Check the Taught By boxes that apply and select an Evaluation option.  You can click on the Mark All Meds as Taught or click on each specific med to apply the Taught By and Evaluation.  Repeat the steps by changing the Taught By and Evaluation if other medications were taught differently. 

The How Taught will show a V for Verbal, H for Handout, D for Demonstration.   Click on the Info box to view the medication information. 

Click anywhere on the medication information to return to the Teaching Detail screen. 

To clear a set of answers on a medication that was added by mistake; first uncheck all answers from the questions at the top of the screen.  Then click the medication that you want to clear out.  Note: to clear answers the Who was taught and Evaluation you will need to right click the answers. 

Pill Box

This screen is intended to help you fill the patient's pillbox. After the screen is set up, it shows the number of pills that should be in each section of the pill box. To view the medication name(s), move the cursor over the number.  The pill box only needs to be set up once and then changed when medications change.

If the Schedule section of the Med History screen is complete, then this screen will show you when each medication is taken (breakfast, lunch, supper, bedtime).  If the schedule has not been filled in yet, you can check the appropriate boxes for each medication on the Pill Box screen.

 

Click on the Import All Meds to PillBox per Schedule button.  This will perform two tasks:

1) Any schedule that was checked (breakfast, lunch, supper, bedtime) from this screen will be imported into the Med History > Schedule screen. 
2)  The Sunday – Saturday pill box setup will fill in the number of meds each day / scheduled time has assigned. 

PillBox Notes
This screen allows you to document miscellaneous information about the pillbox setup.

 

Insulin Syr

If the medication history has an insulin med then you can use this screen to document any prefilled syringes. 

 

Match ICDs

Use this screen to link each ICD code to a medication.  Click the ICD code, then click the corresponding medication.   To use an indicator, check the box for Pain, Supplement or Other and then click the medication.  If Other is selected, you can type in a description before selecting the medication.  

Click SAVE before leaving the screen.  When you click SAVE, the ICD description or indicator will save in the Treatment section of that medication's Med History. 
 

Meds/PillBox Setup

You only need to use this screen if the standard pillbox that is already shown on the Pill Box screen does NOT look like the pill box the patient has.

Use this screen to create the pillbox layout.  You can use our standard layout or create your own by entering the headings separated by commas, then click on Create Pillbox.  If you make changes, click on Save This Pillbox Setup Info. This needs to be done only once to set up the pill box. It will not be repeated on subsequent visits. The only time this will be used after the pill box is set up is if the patient gets a new pill box.

You can also document who the meds are setup and administered by.  This information is also saved in the Referral > Misc screen.  

Capture a patient's signature after a visit in Point of Care Video: Patient Signature on Visit Assessment - YouTube 

Lock Visit Assessment Video: Lock Visit Assessment - YouTube