POC Training - Visits/Assessments

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Have them use the guide, YouTube videos, and other supporting materials.  

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versus printing, as changes are made often. 

Click here for Chart Documentation Manual

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Table of Contents



Starting an Assessment in Point of Care


Where to Start a New Assessment VideoWhere to Start a New Visit - YouTube

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

Using the Schedule feature
  • The most common way is to go to the Select Patient screen and click My Schedules.
  • Select the patient for the visit you need to start.
  • Click the Start Assessment button. 
The alternate way is by going to the Schedule Calendar screen and right click on the schedule.  Left click on the Create Assessment option. 


If you exit the assessment without finishing it, you can select the scheduled visit from the My Schedule button - instead of Start Assessment you will see Edit Assessment.  You can use this button to pull the assessment up to modify it. 
The New button allows you to create a new schedule for the current patient selected.  
This will pull up the Add/Edit Schedule screen. The Edit button allows you to edit the currently selected schedule. The Print button will print the schedule. 

Note: if the Edit Assessment button is NOT active then the assessment has been locked.  You will need to unlock the assessment from the Visits / Assessments screen. 


If you do not use the Schedule feature 

  • Select the patient from the Select Patient screen.
  • At the bottom you can click on New; or
  • Go to the Visits/Assessments screen and click on New. 


Start Screen of an Assessment


Starting the Visits/Assessments Video: Starting the Visit/Assessment - YouTube
Basic Information on Required and Optional Video: Basic Information on Required Optional - YouTube

When starting an assessment in Point of Care you are asked four questions about the type of visit:

Assessment Type: the answer to this question will determine what type of required and optional screens will appear.   The first five assessment types will build OASIS (Start of Care, Resumption of Care, Recert, Special Followup, Discharge).  The Start of Care and Recertification will build a 485.

Payer: The payers that are setup for the current patient will appear.  Select the correct payer for the visit you are completing.

Job Code:  All job codes for your discipline will appear.  Select the correct job code for the visit you are completing. 

Visit Status Code:  Select the correct visit status code for the type of visit you are completing. 

Starting the visit:

Double check or change the date and time as needed.  It is meant to capture the exact time you start the visit at the patient's home. 

If the assessment type if an OASIS type then you will have the M0090 Date to answer as well.  If there is a blinking red X next to the date this means the date is outside of the date range that is appropriate for the assessment type selected.  Verify this date and change it as needed.

Click on Start when those questions are correct.

Verify you have the correct patient selected: A short description of the patient with the chart, age,gender, dob, SSN and phone number will appear. Use this information as a checks and balance to verify you have the correct patient pulled up before continuing with the assessment.   You can copy this information into the Comments section and have it print on the note by clicking the “Copy to Comments” button.  You’ll see the text will be inserted into the Visit Comments section.

Visit Comments: Use this section to document your findings when you arrived at the patients home.  You can also use this area to document anything else that may not be covered in the screens provided. 

Add to 60 day summary: Check the box Add to 60 day summary if you feel the comment information needs to show up on the 60 day summary.  The 60 day summary is found under the Patient Information screen > 60 Day Summary tab.

Text Item: Use the Text Item feature to insert pre-typed text into the Comments section.  Your agency has added common phrases used so that you can automatically insert them into different screens in Barnestorm.  This will help save time and data entry error. 

Add Text Item Code to Every Visit: You can add a text item code to all visits started by using the article listed below. 

https://www.barnestorm.biz:480/kb/KnowledgebaseArticle50818.aspx


Editing a Visit/Assessment


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
Select Patient > My Schedules: Select the schedule and then select the Edit Assessment. 
Visits/Assessments: Select the visit and then select the Edit button.
Schedule Calendar: Right click on the schedule and click on Edit Assessment. 

From Barnestorm Office there are 2 ways to unlock a visit/assessment
Option 1:  Unlock the assessment from Office. From the Visits/Assessment tab, select the visit and click on Unlock. If you cannot access the Unlock button, you do not have permissions to unlock an assessment.  OR the assessment may be too old.  Please have the appropriate member of staff to unlock the visit/assessment using Barnestorm Office; or use Option 2.

Option 2:  Unlock the assessment from Admin. Go to Admin > Unlock a Visit from the main menu.  (NOTE:  If you do not have the Admin button on your main menu, your supervisor/administration has not authorized you to access this screen.)  Enter the patient's name or chart number and then select the visit/assessment that needs to be unlocked. Click the Unlock button in the upper right. If you are not able to unlock your visit/assessment, please review the following article for additional troubleshooting tips:

Unable to Edit/Unlock a Note/Assessment


Vital Signs Screen


Vital Signs Video: Vital Signs - YouTube 

Point of Care > Visits/Assessment > Vital Signs screen. This screen typically shows up under the Required tab. 

Items in red are required to answer. Items in blue or grey are optional. After answering a question, it will turn green. You must answer all required questions in order to mark the Vital Signs screen as complete. 

Temperature requires a method to be answered.  Pulse and Respirations requires Regular or Irregular to be answered.

The Vital Signs History will show all vital signs entered into an assessment, regardless of the clinician who completed the assessment.  


Add Vital Signs Parameters in Barnestorm POC


Add Vital Signs Parameter in POC (Starting time 2:42): Add Vital Signs Parameter in POC
To add vital signs parameters for an individual patient in POC, you'll need to create a vital signs order.



The vital signs parameters will flash on the Vital Signs screen in the assessment note if the number entered is outside of the parameters for that patient. If the patient does not have specific parameters entered, the vitals will flash based on the agency general vital signs parameters.


*Note: If the patient does not have a parameters order then the Vital Signs Parameter tab (from the Vital Signs screen) will state that the agency standard was used. 


Pain Screen


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
The oasis questions will appear regardless of the assessment type that you have selected, but when shown as blue marks they are optional on visits that do not generate OASIS. If they were required, the indicators would be shown as red. 

The Comments is a large text box that will allow you to document anything not covered.   You can free hand type additional information here. 

If the patient does not have any pain, you can indicate that here and also answer who provided the information. You can then move on to another area.

Pain Locations
If the patient does have pain, you’ll need to indicate where and describe it. To do that, click the Pain Locations tab at the top.  There are up to four spots to document pain location.  If you have more than four locations, you can document more than one in the same location if they are close together.  You can also add locations to the comments section. 

Click the asterisk button and you’ll see a diagram pop up for you to select a general location of the pain.  Next, select Anterior or Posterior

From the diagram, click the location of the pain.  You’ll notice that the general location description shows up to the right.  Use the drop down list to specify in more detail where the pain is located.  Click the OK button when the information is complete.   If you don’t find the location you need here, you can also type it in on the main pain location screen.

A common report from patients may be a headache.  To document the pain location of a headache, click inside of the pain location field and type in headache.


Next, you will document the intensity by asking the patient to number the pain on a scale of 0 through 10.  Document the description, exacerbated by, alleviated by and any additional comments you would like to document about the pain.  The documentation for this pain location is finished. 

Pain Meds
Next, you can document how effective the patient’s medications are at controlling pain levels. Click  the Pain Meds tab at the top of the screen.  If the patient currently has pain medications listed in the Med History screen, they will show up at the bottom of the screen.  If the patient is taking the pain medication to alleviate the pain you just documented, click on it and watch it appear at the top of the screen.  The medication name and dose, freq, route will automatically appear.  You can type in when the patient last took this medication.  If the patient is taking a pain medication that is not listed on this screen, you can type the information in as well.

Answer the pain intensity questions for the level of pain before taking the medication, one hour after taking the medication and what pain level is acceptable.  In the effectiveness box, you have the option to type in a description of your own description OR check the box for Meds are effective at controlling pain as observed and reported and watch it appear in the Effectiveness box.  This description will appear on your visit note.

Nonverbal Assessment
If the patient is non-verbal, you will use the Nonverbal pain assessment to indicate the level of pain.  This section is used specific for pain assessment in advanced dementia patients and other non-verbal patients.  There are five categories to observe.  You can review the definition for each answer by clicking on the Definitions button within the category you are addressing.  Once you review the information, click on the definitions button again to make it disappear.  

Check the box for each observation.   The top of the screen will calculate the pain score as you select your answers.  The score of 0 equals no pain; the highest score of 10 would equal severe pain.  This method is equivalent to that of asking the patient to pick a face or a number on a scale to describe their pain.  The non-verbal pain score will print automatically on your visit note.

Teaching
You can document pain-related teaching you provided for the patient by clicking on the Teaching tab.  Check the box for any teaching given to the patient.  Use the comment section at the bottom to document anything not covered in the top section. 

History
Use the History tab to see how the pain screen has been documented for this patient in the past.  You can view the most recent seven assessments that have had pain documentation, or the first seven assessments with pain documented.  You can also view all assessments that have pain documented. 


Wound Assess Screen (New)


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.

This is the new wound screen. It has an easier flow for data entry and also has a tab to document Wound VACs.  If you have used the older wound assess screen, then you shouldn't have any problems transitioning over to the new screen.

You will have the option to create a New Wound or Assess an existing wound.  Note that at the bottom of this main screen you will see the total number of wounds that are or have been treated and the number of wounds that are already marked as healed.  The wounds that are healed will only appear on this screen when you check the box "Show Healed Wounds".  


Either click on New Wound or select an existing wound from the list and click on Assess.   You will be taken to the wound assessment screen.  You will need to document the Identification tab as a requirement.  If the Type does not have a description that meets your needs, then you can type a description in the Other field.  Be sure to answer the Location and Stage if applicable.  The blue icon next to the Stage field will give you definitions of each stage - click it once to make it appear; click it again to make the definitions disappear.

At any time you can click on the Save button and then click on the Back to Wound Selection button to return to the list of wounds. The Comments box is the section where you can enter the wound dressing orders from the doctor.  After entering the wound orders you can click on Add Wound Orders to generate a "No VO Needed".  What this does is it will automatically add the wound orders to this screen so that you will have it ready when you go to assess the wound next time.   If the order ever changes then you can replace the test with the new order and click on Update Wound Order to generate a new "No VO Needed".   The Comments box can be seen under all tabs from the Wound Assess screen.

The rest of the tabs give detailed information about the wound and the wound dressing/change.  The Status tab is used to measure the wound.  You can copy over the last wound measurement by clicking on the Copy from Last Measurements tab; or, if your agency has it setup it will automatically copy over for you.

The VAC tab is new and only shows up under the new Wound Assess screen.  This will allow you to document patients that have Wound VACs. 


Wound Assessment Screen (Old)


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 PosteriorThen, 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.


Create Wound Assessment Linked to the Wound Orders


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:

Create Wound Order from the Order Screen:

·         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. 



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



Review Meds in a Visit


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 a 485 from the Assessment


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

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.) After the visit assessment is complete, go to the Finish screen and Set the End TimeAt 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 an OASIS from the Assessment


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 a Visit


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.  


Patient Signature POC Assessment


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

Finish / Lock a Visit Assessment


Lock Visit Assessment Video: Lock Visit Assessment - YouTube
Optional Features on Finish Screen: Optional Features on the Finish Screen - YouTube