Barnestorm Office has a screen that will show the status of the patient's current episode that reflects new 2018 CoP Requirements. This is a checklist of the patient's individualized Plan of Care. A green check mark will appear if the requirement has been fulfilled; a red check mark means the item has not been complete.
Each item will either show the data keyed in the system or it will be marked as not found for this period.
If an item is not found, the top section of the screen will tell you where to document the missing piece. Below is a running list of where to find each item.
Diagnoses: ICD History
Medications: Med History, dated on or before the admit date
Equipment: 485 box 14
Safety Measures: 485 box 15
Nutritional: 485 box 16
Allergies: 485 box 17
Functional: 485 box 18A
Activities:
Cognitive:
Prognosis: 485 box 19
Orders: Looks for a verbal order (non FYI) dated during thetime frame selected
Frequency: 485 or Verbal Order frequency
Interventions: Looks for an entry from the Care Plans screendated for the time frame selected
Goals: Looks for an entry from the Care Plans screen datedfor the time frame selected
Teaching: Looks at the Visits/Assessments > Teachingscreen for a visit dated during the time frame selected
Advance Directives: Referrals > Advance Directives
Emergency Plan: Referrals > Emergency Plan
Risk: Referrals > Emergency Plan > Risk