To add a diagnosis-based care plan:
1. Go to Care Plan.
2. Click the Add Plan button.
3. Next to Discipline at the top of the screen, select the discipline, such as SN for Skilled Nursing.
4. The 485 dates, if they exist, will pull automatically. If this is a SOC or resumption, put in the dates for the care episode (60 days). This will generate the dates for each week of care.
5. If you know how many visits per week, you can indicate it at the top. Then you can increment each week up or down as needed by clicking on it. If you don't know yet, you can leave this part blank and add it later.
6. At the bottom half of the screen, click the Pull from Diagnoses Button.
For nursing care plans, you'll see the active ICDs for this patient appear below this. Each diagnosis code has associated interventions and goals, which you will be able to select from, set targets for, and track in visits.
For therapy care plans, you'll see the PDGM clinical grouping that applies to therapy, such as musculoskeletal rehabilitation.
IMPORTANT: Use the minus button on the left to remove any diagnosis codes that you will not be providing care for--this will reduce the number of interventions that don't pertain to the care you're providing.
7. Click the Interventions tab to see the interventions.
8. To remove interventions, click the one(s) you want to remove and then click the red minus button to the left.
9. To edit an intervention, click it and then click the pencil button. This will allow you to change the text of the intervention.
10. To add a different intervention, click the plus button and then type it in.
11. Click the ST Goal tab to see the short term goals.
12. To remove goals, click the one(s) you want to remove and then click the red minus button to the left.
13. To edit a goal, click it and then click the pencil button. This will allow you to change the text of the intervention.
14. To add a different goal, click the plus button and then type it in.
15. Optional: if you'd like to add a target % for each goal, you can either add them to all at once or individually. These percentages indicate what percent of improvement you expect a patient to achieve over the episode timeframe. You'll use this as a way to track progress to the target on each visit.
16. Long term goals (on the LT Goal tab) work the same as short-term goals, and are optional--usually just therapists use this part, not nursing.
17. Click the Save Plan button in the lower right.
Care Plans and Schedules
1. To generate scheduled visits based on the care plan, click on the Schedule tab in the plan.
2. Select the employee, patient program/payer, job code, and visit code. Keep in mind that you can easily switch employees on the schedule as needed, so this is just the employee who will normally visit.
3. If you know the preferred days of the week, select those.
4. If you know the preferred visit times, enter those. As always, you will have control over these on the schedule, and the system will allow you to complete the visit any time, so this is just a guideline.
5. Click the Create Schedules button. This will generate all the visits shown on this care plan and put them on the schedule.
6. You'll see in the upper window how many visits are scheduled & completed, as well as any PRN visits.
7. If you need to modify the employee or date or time on any of these scheduled visits, you can simply go to Schedule and do so.
The timeline tab includes the current 485, any supplemental orders within this episode, as well as progress on the current care plan.