1. Therapy Guide
July 2019

2. Table of Contents Evaluation & Treatment 4 Goal Overview 5
Goal State: New & Active
Goal: Discontinue/ Discontinue & Clone
Non-Medication Orders
Order Overview
Processing Orders

3. 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

4. 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

5. 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.

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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