Therapy Guide July 2019

Table of Contents Evaluation & Treatment 4 Goal Overview 5 Goal State: New & Active 6-7 Goal: Discontinue/ Discontinue & Clone 8-9 Non-Medication Orders 10 Order Overview 11 Processing Orders 12-14

Evaluation & Treatment Initial Eval & Re-Eval Therapy Initial to Eval is started via the chart: assessment Upon submission it is moved Ops – Clinical QA for approval Once approved in QA it moves to Ops – Clinical Orders to be sent to MD Daily Notes Daily notes are completed via the Mobile App Goal Baseline & Progress get recorded and update the LPR when visit is submitted Therapy Live Patient Record Once initial therapy eval passes QA the LPR gets created Daily visit note activity live updates goal progress in the LPR Re-Eval will impact the LPR once it passes QA Goal Baseline & Current Progress When goal baseline is recorded in daily note it will be visible in subsequent daily notes & the LPR Current progress (all activity after baseline) is recorded in daily visit and is visible in the LPR

Goal Overview Short Term Goal Type: Standard & Custom Standard: pre-loaded into the system & attached to LTG Standard: may include brackets [ ] for patient specific parameters Custom: allows user to create all custom text Custom: Allows user to create custom LTG Start Date Defaults to todays date Certification start date should be used for initial eval Next certification date should be used for re-evals End Date Should not be used pre-emptively i.e. if cert period ends 3/31 do NOT enter end date of 3/31 End date should be left blank until goal is achieved/ modified Long Term Goals Standard short term goals all mapped to a standard LTG Standard goals may be used multiple times in single assessment When custom LTG is created it may be used multiple times

NEW (not yet charted against via the mobile app) Goal State: New NEW (not yet charted against via the mobile app) Once a goal has been added to a patient eval/ LPR it cannot be deleted Prior to any electronic charting being completed it can be edited and saved Example: User adds a goal ‘Patient to walk 10 feet with min assist…’ but needs to be 20 feet.

ACTIVE (has been charted against via the mobile app) Goal State: Active ACTIVE (has been charted against via the mobile app) Once a goal has activity & has been charted against via the Mobile App it is no longer editable and all fields are greyed out except end date User has two options: discontinue and clone or discontinue now Discontinue & Clone: as of end date discontinues goal while creating a copy to be edited & saved for changes Discontinue Now: as of end date discontinues goal without copying forward

Goal: Discontinue and Clone Purpose: An active goal is being modified Step 1: Enter end date of the current goal; i.e. 3/31/19 Step 2: Click Discontinue and Clone and accept acknowledgment Step 4: select start date of new goal; i.e 4/1/19 *will default to end date of the discontinued goal but should be changed unless both should be active on the end date Step 3: make appropriate changes that reflect the new goal Step 4: Save Discontinued goal will drop below red (discontinued) line & new goal is active

Purpose: An active patient goal is being discontinued Goal: Discontinue Purpose: An active patient goal is being discontinued Step 1: Enter end date of the current goal; i.e. 3/31/19 Step 2: Click Discontinue & accept acknowledgment Step 3: Save Discontinued goal will drop below red (discontinued) line and no longer be visible in the mobile app after end date.

Order Type: NON-MED/COMMUNICATION NON-MED/COMMUNICATION: To be used for orders that are not medications or to record communication notes for medical record. Physician drop down will show all physicians attached to patient & Unattached Physician to allow for typing a name when an MD is not yet attached to patient profile Non-Med/Communication Order get added to the LPR via Ops-Clinical- Orders when they are processed to send to the MD for signature Examples: changes to patient treatment plan; communication notes regarding patient

Orders Overview Order states: new; pending MD signature & completed Order types: New, Clarification, Discontinue & Non-Med ID: Every order is assigned a unique order number Patient Name is linked directly to patient’s LPR Last Note can be hovered to view most recent note user saved Attachment: Ability to mark as completed w/ MD Signature PDF of Order Add/ view order attachments

Processing Orders (New) When an order is created it is sent to Ops – Clinical – Orders: New to be processed This includes evaluations; re-evals; 485, med orders & non-med/communication orders By checking the box on the left user may ‘send to MD’ which moves order to Pending MD Signature Status; Delete order if it was created in error; or Complete w/o MD Signature which moved order to a status of completed bypassing Pending MD Signature If an order needs to be edited, user may click on the line to make changes before processing Non-Med/Comm order must be processed one at a time to indicate which section of patient LPR they are assigned to

Processing Orders (Non-Med/Communication) From the Order Managers page (New) check the box Click Send to MD Select service type (PDN, PT, OT, ST) If this order does not need to go in the LPR, click skip If a goal is being added to the LPR select group Create Goal Click Save The order will be moved to Pending MD Signature The new goal will be active in the LPR

Processing Orders (Pending MD Signature) Once an order has been sent to MD it is moved to Pending MD Signature By checking the box on the left user may delete order; re-send to MD which updates the ; Delete order if it was sent in error; or Complete w/o MD Signature which moves order to a status of completed Re-send to MD will update ‘Date sent to MD’ Adding an attachment will prompt user ‘Mark as completed with Signature?’ If yes completes order Once an order is completed drops off list and is marked as completed in patient chart Adding an attachment functionality also works directly from individual patient chart – orders tab

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