Roadnotes Home Health Recertification Process

Client Name

RoadNotes®

RoadNotes Home Health Recertification Process

HomeWorks Version 5.1

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Revision: / Cerner Corporation. All rights reserved. This document contains confidential and/or proprietary information belonging to Cerner Corporation and/or its related affiliates
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Table of Contents

RoadNotes Home Health Recertification Process......

Event 1 – Review your Home Page......

Step 1 – Review your schedule......

Step 2 – Review In-Progress Workflows......

Step 3 – Review In-Progress Profiles......

Step 4 – Review your Inbox......

Event 2 – Complete the Recertification Visit......

Step 1 – Complete MSP Profile......

Step 2 – Complete Certifications......

Step 3 – Review/Add Diagnosis......

Step 4 – Add New Billable Diagnosis History if Appropriate......

Step 5 – Complete Contact – Appropriate OASIS Profile......

Step 6 – Add Visit Orders for New Certification Period......

Step 7 – Optional Use of Order Sets......

Step 8 – Review Non-clinical Information......

Step 9 – Review Physicians......

Step 10 – Review Resource Assignments......

Step 11 – Review Advance Directives......

Step 12 – Review Supply Orders......

Step 13 – Update Care Plan......

Step 14 – Review Medication Orders......

Step 15 – Review DME Orders......

Step 16 – Review Patient Acuity......

Step 17 – Write Patient Summary......

Step 18 – Enter Supplies Used......

Event 3 – Review 485 for Accuracy......

Step 1 – Review through Report Approval......

Event 3a – Make necessary corrections to the medical record......

Event 4 – Complete the Contact......

Event 5 – Notification of Completed Recertification......

Step 1 – Start Secure Messaging......

Step 2 – Start a New Message......

Step 3 – Find the Recipient......

Step 4 – Send the Message......

Event 6 – Synchronize the laptop......

Reports......

Review Personal Productivity......

Chart Management folder | Plan of Treatment/485......

Employee Schedule......

Current Medications Report......

Visit Note Report......

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RoadNotes Home Health Recertification Process

RoadNotes Home Health Recertification Process

Event 1 – Review your Home Page

Step 1 – Review your schedule

View your schedule in a day, week, or month view. View the Employee Schedule reports by selecting from the View Report dropdown. Click the Assigned Patients dropdown arrow for a list of all patients assigned to you. Adjust the Time Display by selecting from the dropdown list.

If one hour is selected for the Time Display, the above schedule displays with the patient name in the view.

Step 2 – Review In-Progress Workflows

If a workflow is less than 100% complete, it will list as an In-Progress Workflow. Single-click on the workflow row to open the workflow at the first incomplete step in the workflow.

Review your In-Progress Workflows for any incomplete flows.

Step 3 – Review In-Progress Profiles

If all profiles have been completed and locked, there will be no profiles showing in this list. Review the list to make sure all profiles have been locked.

Step 4 – Review your Inbox

Review Notices/Reminders

Review your Inbox to see which Recertification are due.

If you are completing the recert visit and there is a notice, click on the notice for the specific patient. This will take you directly to the patients recertification screen. Enter the information and save.

Review Secure Messages and Notices

Review your Inbox for any new messages, notices or alerts and tasks.

Event 2 – Complete the Recertification Visit

Step 1 – Complete MSP Profile

Select the Current Admission. Click on the MSP Profile button on the Ribbon Bar.

The following screen will appear. Use the drop down and select Medicare, click Add MSP Profile then click View MSP Profile.

Step 2 – Complete Certifications

Enter the number of days for the recertification period, Receiving Staff, and Prognosis. The name in the Receiving Staff field prints on the POT/485.

Complete the tabs for Functional Limitations, Activities Permitted, Mental Status, Safety, and Nutritional. Leave the Authorization screen and MD Summaryfield blank.

Save when finished.

The Recertification notice will be automatically turned off when the new certification period is added.

WARNING: Do not turn off the recertification notice at the certification screen unless you want the notice to be turned off permanently.

Step 3 – Review/Add Diagnosis

Click the icon next to Diagnosis. Then click the icon next to Active.

The Diagnoses attached at Intake will appear under Active. Review these diagnoses for accuracy. If you find an incorrect diagnosis, edit the record and enter a stop date equal to the start date. These Diagnoses are a bucket of all diagnoses and are not prioritized at this level. Click the Add next to Diagnosis to enter a new diagnosis. Hospice often indicates a prognosis of Terminal or 6 months.

Required: Exacerbation, Onset, History of or None

Click the ellipses button to the right of the Diagnosis field to search for a diagnosis.

Search Options

The search screen opens with the Commonly Used list as the default view. If your diagnosis is in the Commonly Used, click on the diagnosis to select.

Commonly Used

A filter displaying a list of diagnostic codes set up by the agency in File Maintenance. The codes display automatically when the window opens.

Body Systems

Filters by diagnostic codes according to body system. Choose the body system from the list by clicking the down arrow to the right of the field. Click the ellipsis button to execute the search and to display a list of codes for that body system. Highlight the code. Click Select.

If the Commonly Used Only box is checked, the search produces diagnoses of the selected body system that are listed in the commonly used list. If the list appears to be incomplete, uncheck Commonly Used.

ICD-9 Code

Allows the user to search by the specific three-digit code. Click in the search field and type in the 3-digit code. The window will display the list of codes that match the criteria. Click the code to select.

NOTE: If only 2 digits are entered, then the search only locates codes with those digits after the decimal point. (see below)

Description

Allows the user to search by the specific code description. Click in the search field and type the name or part of the name of the diagnosis. As the letters in the description are typed, a list of diagnoses descriptions containing those letters appear in the list.

Step 4 – Add New Billable Diagnosis History if Appropriate

If new diagnoses have been added to the chart, or if current diagnoses are no longer pertinent to the patient’s care for the new episode,create a new Billable Diagnosis History.

Click the + sign next to Billable Diagnosis. Click Addthen Click the Blue + sign to enter Diagnosis

Only those diagnoses entered in the Diagnosis node will be available to add to the Billable Diags screen.

To select, highlight the diagnosis on the left and click the center arrow to move to the right. Repeat until all diagnoses that must be on the 485 are selected.

Click Save.

Diagnoses selected for the Billable Diags screen print to the 485 and flow to the OASIS. These are the billable diagnoses.

Once the selected diagnoses are listed in the Billable Diagnosis History screen, they may be moved up or down in priority by highlighting a diagnosis and clicking the green Upward/Downward arrows appropriately.

The code associated with a diagnosis can be changed by clicking on the diagnosis to highlight, then clicking the Specify button next to the ICD-9 code.

This lets you choose within the numeric range of the original diagnosis and change it to the appropriate diagnosis. Click on the correct diagnosis. This will change the diagnosis in Billable Diagnosis and also the diagnosis at the Diagnoses level on the tree view.

Verify the Physician to Print on Bill is the physician you want to print on the 485. If the physician is not correct, use the drop down list to select the appropriate physician. Click the Save button.

Step 5 – Complete Contact – Appropriate OASIS Profile

Add a new post-admission contact and complete the OASIS C – Fup/Recert OASIS for the appropriate discipline. When finished, mark the profile as Completed, do NOT lock.

Right click the appointment in the Scheduling Plug-in and select Complete Appointment.

The Contact can also be entered by clicking Add next to Contact.

Contact Details

Select the appropriate Time Type, Contact Date, Admission, Visit Order, Appointment, and Service.

If this contact was created from the Scheduling plug-in, this information will be pre-populated. Review to verify the information is correct for this visit.

The Staff field populates with the user who is logged on and the Branch field populates based on previous information. Select the Visit Type and Place of Service.

Time and Mileage

Review the Arrival Time that was pre-populated based on the appointment time. Adjust the time to indicate the actual arrival time. Enter Travel time and Total miles.

Click SAVE when finished.

If an appointment was not available to select, you will receive a message asking if you want to create an appointment for this contact. Click Yes.

Attach the appropriate profile

Click the <Add New Document> on the Ribbon bar. To attach the appropriate documentation to your visit, select from the list. Highlight the profile to select. Click the “Add” button to attach the profile to this visit/contact.

Step 6 – Add Visit Orders for New Certification Period

Click"Add" to add visit order frequencies for the new cert period.

The visit orders will have an Order Receipt date of the date of the recert visit. The Start Date will be the first day of the new cert period.

Check the box Print on POT only and not interim orders.

Enter visit orders as directed in the admission process.

PRN Visit Orders

Click Add next to Visit Orders in the tree view.

Select the Admission, Discipline, and Status.

Check the box next to PRN order and enter the visit order duration.

Complete the remaining fields, and SAVE.

Step 7– Optional Use of Order Sets

Click Quick Add next to any order on the tree view. Select Order Sets from the Consolidated Order screen.

Attach order to Admission / Pending Referral / All – Select an option to associate all orders in the set with an Admission or a Pending Referral or All.

If Admission or Pending Referral is selected, a drop-down list allows selection of the appropriate program and date.

Start Date – Select the Admission date

Order Receipt Date – must be on or before the Admission date for these order, goals and interventions to appear on the POT/485.

Ordering Physician – If a physician does not default to the field, select the physician who ordered the set.

Receiving Staff – Select the employee who received the order from the physician.

Status – Select the status of the order.

Lock records if applicable – Check this box to lock the start portion of these orders. The start portion will be locked if record locking functionality has been activated in File Maintenance for the appropriate division, program, or branch.

Complete the specific information required for the orders listed.

Step 8 – Review Non-clinical Information

Enter any changes needed in Patient Level, Payer, or Care Giver screens.

Step 9 – Review Physicians

Click on the + sign next to the Physicians. Listed under <Active will be physicians who were caring for the patient. Add new physicians or enter a stop date on existing physicians as appropriate.

Step 10 – Review Resource Assignments

Click the + sign next to Resource Assignments. Enter a record for each new discipline or employee on the patient’s case. Be sure there are no change to the primary resource assignment. Enter new vendors that are associated with the patient. Enter Stop Dates for any resources no longer working with the patient.

Step 11 – Review Advance Directives

Click on the + next to Advance Directives. If there are new advance directives, click on <Add> and enter the appropriate information. Enter the date stated on the directive. If no date is available, use the date of the recertification visit as the start date.

Step 12 – Review Supply Orders

Enter new supply orders if needed.

Click on the + sign next to Supply Orders. Click <Add> and search for the supplies. Complete the supply entry. Check the Lock Records if Applicable box.

The ORDER RECEIPT DATE will be the date of the recertification assessment.

Step 13 – Update Care Plan

To Add to Care Plan

Problems/Clinical Pathways. Click <Add>. Complete the fields in the Care Plan screen.

Add Goals and Interventions as appropriate.

Select Goals and Interventions by highlighting the items. Remember that highlighting the problem will select all goals and interventions related to that problem. Click again to deselect if necessary. You may select more than one problem with its goals and interventions. You do not have to select one problem at a time. Edit the goals and interventions as necessary toindividualize the problem for the patient. Click Save.

Step 14 – Review Medication Orders

To review medications, click on the + sign next to the Medication orders, then click on the + sign next to Active. Select Add to add new medications.

The Order Receipt Date will be the date of the recert visit. The Start Date must not be a date prior to the Order Receipt Date. Complete the remaining fields. Signature Required should be checked

Discontinue any medications that are no longer appropriate.

Step 15 – Review DME Orders

To review DME orders, click on the + sign next to the DME Orders, then click on the + sign next to Active. Click Add and add any new DME. The Order Receipt Date will be the date of the recert visit. The Start Date must not be a date prior to the Order Receipt Date. Complete the remaining fields. Signature Required should be checked if a PIO is needed.

Discontinue any DME no longer needed.

Step 16 – Review Patient Acuity

Click the icon to the left of Acuities. If the acuity level has changed, click Add and enter the new level. Click save. Associate an admission with the acuity level.On the previous record, enter a stop date. Select the Acuity scale from the drop down list. Enter an Acuity Value. Click the Save.

Step 17 – Write Patient Summary

This is a discipline-specific summary. Complete the free-text field. Save and lock the summary.

Step 18 – Enter Supplies Used

Click on Add next to Supplies Used. From the drop down at the end of the contact field, select the contact, which the supplies were taken. In the Supply column, choose the supply from the drop down. Enter the quantity of the supplies taken. Enter a record for every supply taken. When finished, click Save.

Select the contact, select the supply used, enter the quantity, once complete Click the Save button.

Select the contact from the drop down menu where the supplies were used.

Select the supply and enter the number of each item used.

Once all supplies used have been added, click save on the top ribbon bar.

Event 3 – Review 485 for Accuracy

Step 1 – Review through Report Approval

To review the POT/485, go to Report Approval; double click on the POT/485 to review. If corrections need to be made, return to the Patient Tree view, make the necessary changes and review the POT/485 again for accuracy. DO NOT APPROVE or LOCK the record. This is strictly a review by the admission clinician.

Click on the Reports icon.

Select the Chart Management folder and then select the Plan of Treatment (485) report and click Next.

Check the Choose Certification Period (s) box.