Wound – When a patient has a wound assessment that has been entered into a visit, you can select the wound from this dropdown and create an order for wound care. The wound orders will then show up on the visit assessment when documenting on the assigned wound.
Labs – Select this category if you are entering repeat labs for a patient. The labs will show up while on the Labs screen within the visit assessment. You can view the labs or you can select the lab order to add that documentation to your visit assessment.
IV/Injections/Feeding/DEM/Supplies– These work the same as the Labs category.
Admission/Resumption – The patients current ICD history and med history will be inserted into the order. There’s an optional phrase at the end for the doctor to mention any specific parameters they want to set for the patient. Any text can be modified or added, as needed.
Post Hospital/RecertOrd –
Recert Order: Inserts most recent patient information (depending on the number of days you specify to look back), including, the next cert period, “Date Faxed”, current ICD history, current med history, template of disciplines for you to enter the frequencies, orders and goals from the most recent 485 or assessment.
Post Hospital: Inserts most recent patient information (depending on the number of days you specify to look back), including, details of facility history, current ICD history, current med history, template of disciplines for you to enter the frequencies, orders and goals from most recent 485 or assessment.
Medication – When medication changes are completed in the med history screen, you can pull the changes into an order without having to retype the information. The sequence of the order needs to be: make changes in the med history then pull up a medication order. The doctor must match in the med history and order screen.
Discharge – If patient already has discharge info entered on the referral then the discharge date and reason will be inserted into the order. If it has not been entered into the referral yet then a place for you to type in the information will appear. A history of visits per disciplines will generate. Also, diagnoses from admission, place to summarize the care, section to document follow up plans,current ICD history, current med history and a phrase to thank the doctor for their referral.
Transfer – If the patient will be transferred to another facility you can create a summary with the following info: phrase “Patient will be transferred on”, disciplines including the number of visits done, ICD history at time of admission, place to document summary of care, current ICD history, current med history.
Parameters for notifying MD – You can setup patient specific parameters instead of using the agencies general parameters. If a patient has specific parameters, you can receive a warning message within the vital signs screen of the visit assessment when a vital sign outside of the parameter is entered. A pop up box with the patients doctor information will appear.
Face-to-face –This will insert pretyped text for Face-to-Face documentation that needs sent to the patients physician. This category is linked to keeping track of Face-to-Face orders mailed and not/returned.
Advanced Directives - Pulls up the Customize order content screen with Advanced Directives and Emergency Plan selected. This will pull all information from the Referral > Directives and Emergency Plan (or within the assessment, both are tied together).
Next to the Type drop-down list is the Insert Med Interactions: Select this button to insert the text from the Med History > Interactions report. **Note: this feature will only be available to those employees who are setup to use the Med Interaction feature from the Med History screen.