POC Training - Chart Documentation

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Table of Contents



Add ICD Codes for a Patient (Home Health Only)


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.

You can key up to 50 ICD codes into the history.  Note that only the first 15 will pull into the 485. However, claims will include up to 24. 
The Cert Period dates shown will tell you the 30 day period and if it is the first or second set of 30 days within the 485 period. If the 485 icon does not show up then that means the 485 episode has not been generated yet.  

Step 1:  Adding a New Effective Date

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.

7Select 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.

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



Edit ICD Codes


Edit ICD Codes


Change the order of codes

You can change the order one of two ways:

ReOrder

Move Up / Move Down

 Delete ICD Codes
  • Create a new Effective date for when the condition no longer exist - Under Step 1 add a new date and then click on New Date.  The most recent codes will copy over to the new Effective Date.   
  • Click one the code that need deleted. The code will be highlighted after you click it.
  • Click the Remove This ICD Code From the List button. The code will disappear from the list.
  • After deleting appropriate codes click on the Save All Changes button.


Add Surgery Codes for a Patient


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

Edit Surgery History

Delete Surgery Code


Add a Medication for a Patient


 o   All other boxes are optional.

 o   There’s an option to translate the abbreviations to words or to make all letters uppercase.  

 o   Click on Build Dose/Freq/Rte button. 

 o   An error message will appear if any required boxes were left out.

 o   The information will show up in a Dose/Freq/Route format. 

 o   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.


Change Dosage for an Existing Medication


This will show you how to update the dose and/or frequency for a medicine already in the Barnestorm system. 

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


Edit Medicines for a Patient


You would edit a medicine if you made an error when you entered it. 

IMPORTANT NOTE

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 New Dose/Freq/Route tab to add new entry.  

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


Add the Start and Stop for a Short-Term Medication at the Same Time


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 Same-Day Dosage Changes for Medications


This process is used for the rare cases a medication has multiple updates for one date.

    Discontinue Medicine


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

    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”.


    Messaging


    Messaging Video: Messaging - YouTube 
    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.  
     
    Creating new messages

    New messages can be created from several points within the software, including the Referral screen, Scheduling screen and the Messaging screen.


    • To create a new message from the Messaging screen, from the main menu, click Messaging.  Click the New Message button.  This screen will appear:
    • Recipient, subject and message text are required, the chart number is optional.  Uncheck "Active Patients Only" to search for discharged patients. 
    • Send To options will include One or more employees, All Employees (this will select ALL active Barnestorm employees), or a Team of employees that has been setup under codes.  See Employee Team Codes article on how to setup teams. 
    • Messages can be sent and delivered at a future date.  This is particularly useful for visits or reminders that need to happen in the future.  To create a message that will send in the future, uncheck the box that says Messages should be delivered immediately.  Then fill in the date and time that the message should be delivered.
    • Select how the message should be sent to the user; Barnestorm Message, Email, or Text Message.  See the attached article on how to setup Email and Text.  
    • To send the message, click Send.
    • *Point of Care users will have to sync to send their messages.

    Receiving Messages

    Once a message has been sent to you, a notification will pop up in the lower right-hand corner of your screen and across the Messaging button from the Main Menu.  It will look like this:



    • Clicking the text at the bottom that says Click to confirm receipt of this message will mark the message as Read and it will not pop up anymore.
    • The message will continue to pop up until you mark the message as Read or delete it from the messaging screen.
    • Clicking the text that contains the sender and the subject will display the message for you in this window:

    • This window is a read-only view of the message that you just received.
    • To mark this message as Read and discontinue the notifications associated with this message, click Mark as Read.
    • To discontinue receiving future messages, click Turn Off Alerts.
    • *Point of Care users will have to sync to receive and send new messages.
    Reply to Sender
    Once you have the message pulled up you will have a few options on replying: 
    • Click Reply to reply to employee who sent the message.  Click All to reply to all employees in the message.  To select new employees to send the message to, click Forward and search for the employee in the To field. 
    • You can also Print or Delete the message from the preview. 
    Create a Reminder
    You can setup a reminder message for yourself to pop up at a specific date/time.  
    • Click on New Reminder at the top of the Messaging screen.
    • Patient is optional, enter a Subject and text message.
    • Select a date and time to receive your pop-up reminder. 
    • Click on Save
    • Your reminder will pop-up at the bottom, right corner of your screen on the date/time it was setup to reminder you. 
    • Double click your reminder pop-up to Dismiss, Snooze, Print or Delete the reminder. 

    Patient Emergency Plan


    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:

    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/ 

    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.



    Fall History


    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

    Edit Fall

    Delete a Fall

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


    Print Falls

    Fall History > Edit Fall or Add Fall
     


    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. 

    Fall History Main Menu in Point of Care



    Fall History > Edit Fall



    Transfer a Patient in Point-of-Care


    How to add a transfer OASIS in Point of Care.  This also walks you through adding the facility information where they were admitted. 

      Create Verbal Orders


      Create Verbal Order Video: Verbal Order - YouTube
      This video looks outdated, for most features they are still the same process.

      Using the Order Builder Video: New Barnestorm Order Builder - YouTube



      Add Care Coordination Note


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






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


      Copy to Comments Feature in Point of Care Assessments


      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.