Part 3- New Skilled Nurse Note
The new skilled nurse note, scheduled for release January 2018, supports agencies with best practice processes, including clinical documentation improvement with embedded QA elements.
The new skilled nurse note enhances the ease and quality of documentation, especially the patient’s need for skilled nursing services based upon their identified problems. [CoP-484.75(b)(1-7); 484.110 (a)(2-3)]
- Ability to clearly identify if a patient is a DNR, Fall Risk or High Risk for Hospitalization on every clinical note [CoP-484.60(a)(2)]
- Ability to View Original Plan of Care and POC Summary for all changes to the plan of care on every clinical note [CoP-484.60(c)(1)]
- Plan of Care Summary gives ability to see all interventions [CoP-484.50(c)(5)]
- Ability to see last set of vital signs entered by all disciplines [CoP-484.60(d)(3)]
- Able to view vital sign log for more information
- Validation of vital signs documentation
- Added ability to document Additional Vital Signs, including PT/INR
- Ability to document quicker by focusing on problem oriented charting
- Ability to document problems completely
- Ability to enter New Wound Manager from skilled nurse note
- Ability to document Infection Control and enter Infection Control log directly from the patient chart [CoP-484.70]
- Home bound narrative generates from OASIS Assessment for all notes and editable [CoP-484.55(c)(3)]
- Ability to document patient response to plan of care and notification of changes to plan of care [CoP-484.60(c)(3)(ii); 484.60(d)(5)]
- Ability to document care coordination with physicians and care team members [CoP-484.60(d)(1)-(3); 484.50(c)(5)]
- Access to document coordination note directly from the SN note
- Discharge planning notifications to patient/representative and all physicians on the case [CoP-484.60(c)(3)ii]
- New Health Management section to document those aspects of care that are directly related to patient outcomes
- Requires SN to enter Medication Profile every SN visit to review and reconcile drugs. Automatically opens Medication Profile and generates green check mark for completion of task
- Prompts to document medication issues, issues that may impact plan of care, s/s of heart failure and other co-morbidities [CoP-484.110; 484.60(c)(3)i]
- Ability to document Interventions/Training [CoP-484.60(d)(5)]
- Ability to document response to Treatment/Goals [CoP-484.110(a)(1),(3)]
- Ability to utilize templates
- Clinical Pathways which will automatically generate interventions into this section (2nd quarter of 2018)
- Medical necessity generated from OASIS documentation on every note and editable [CoP-484.55(c)(3)]
- Ability to document narrative note with access to templates
- Narrative Assistant feature provides the ability to automatically generate a narrative note that includes the seven essential elements of a billable note per CMS guidelines (1st quarter 2018)
- Ability to enter supervisory visits directly from the SN note (1st quarter 2018)
