When creating a 485 from an assessment, you can pull over other discipline’s Orders/Goals from their assessment. To follow this method, only one clinician can create the Start of Care or Recertification assessment type. The other clinician will document their orders and goals under the Orders/Goals section on their visit note. 

Instructions for clinicians who are NOT creating the 485

The assessment type you select cannot be the Start of Care or Recertification assessment type - only one user can use this type and it will need to be the user who creates the 485.  

• Select the Orders/Goals screen from either the Required or Optional list of your Visits/Assessments. 

• You will use the Box21: Orders and Box 22: Goals tab to document your plan of care. 

Box 21 should include your frequency. Be sure to use a format your agency has approved. Ex. PT: 2 WK 7. This will allow the frequency to show up in different areas of the software. 

Use the Text Item feature to insert predefined text.

Use any of the onscreen buttons to pull additional information from past visits. 

Freehand type additional information that is not covered from the Text Item or onscreen buttons. 

• Continue to document the rest of the note as you normally would.  As needed, you can select the Menu Style > Required/Optional Screens. 

Instructions for the clinician who is creating the 485 from their SOC or Recertification assessment type

Before pulling over the information, you’ll want to make sure the other clinician is finished with their documentation and has synchronized Point of Care.  This feature will look for the most recent Orders/Goals going back 10 days to 20 days after the current assessment.

• From Point of Care start or edit the patient’s Start of Care or Recertification assessment type.

• The person creating the 485 can enter their Orders and Goals into the Orders/Goals screen.

• From the Box 21 and 22 tabs, click on the Build from Disciplines button.  (This step can be repeated if corrections were made to the other disciplines Orders/Goals at a later time).

• The most recent orders and goals from other discipline’s assessments will pull over for that patient.

• The information pulled over will be added to the bottom of the page.

• Build the 485 as you normally would from the Finish screen of the assessment. 

 *Note: Each time you click on the Build from Disciplines button, it will add another copy of the other disciplines orders and goals at the bottom of the page.  If the other disciplines made a correction to their Orders/Goals text and you Build from Disciplines again, you will need to delete the previous text before or after you pull over the new information.  Be careful not to delete your own information. 

*Troubleshooting:  If the correct information is not pulling over, then check to see if there were multiple Orders/Goals documented recently.  Ie. if there were two different assessments that have had Orders/Goals documented, only the most recent will get pulled.