Clinician s Guide to Using Clinical Pathways

Transcription

1 Clinician s Guide to Using Clinical Pathways and Order Sets March, 2010 OASIS Assessment Training Manual 01/2010 CE

2 Table of Contents Page 1. Definitions 1 2. List of Order Sets Currently Available 2 3. Things to Keep in Mind When Following a Pathway 3 4. Initial SOC Using an Order Set (RoadNotes) (RN) Routine Visit Using a Clinical Pathway (RoadNotes) (all SN staff) 6. Initial SOC Using an Order Set (HomeWorks) (RN, Clerical Staff Entering a SOC) 7. Routine Visit Using a Clinical Pathway (HomeWorks) (All SN Staff and/or Clerical Staff Entering the Data from a Routine Visit) SOC or Recert with Paper Documentation 46

3 Definitions Definitions: 1. Clinical Pathway A group of interventions and corresponding goals that are based on the routine care expectations for an illness, condition or diagnosis. 2. Order Set A group of recommended orders for a specific condition or illness. These include the recommended frequency and duration of services, the routine and non routine supplies and equipment usually associated with the condition, the related Clinical Pathway. The Order Set may also include Recommended/Preferred Protocols for the clinician to select. 3. Preferred Protocol A group of interventions that are meant to act as guides for clinical decision making based on the clinical assessment and physical presentation of the condition. 4. Primary Pathway The Clinical Pathway that is associated with the most problematic issue for the client at the time that the assessment is made. This can be specific from one discipline to the other. Example: Skilled Nursing care may be primarily focused around Diabetic Teaching and Physical Therapy may be primarily focused on improving safe mobility. The SN Primary Pathway may be Diabetes and The PT Primary Pathway may be related to Altered Mobility or Safety 5. Secondary Pathway(s) The Clinical Pathway(s) that are important to the care of a patient in the episode, but are adjunctive to the Primary Pathway. Only interventions and goals that pertain to that specific condition are included in order to prevent them from duplicating steps already included in the Primary Clinical Pathway. Example: The care plan for a patient with a diabetic foot ulcer has the Primary Pathway related to the care of this Chronic Wound, the patient also requires teaching to help manage his Diabetes and CHF. Diabetes and CHF would represent Secondary Clinical Pathways for this patient. Clinical Pathways and Order Sets Page 1 of 46

4 Current Available Order Sets Primary Order Sets These include suggested visit frequencies, all routine and anticipated supplies, routine DME, and associated primary clinical pathway. Order Sets for wounds also include the Preferred Protocols for treatment options. 1. Congestive Heart Failure 2. COPD / Chronic Respiratory 3. Diabetes, Newly Diagnosed, with Insulin (Only available as a Primary Order Set) 4. Diabetes, Newly Diagnosed, without Insulin (Only available as a Primary Order Set) 5. Chronic Diabetes 6. Stage 1 and 2 Pressure Ulcers 7. Uncomplicated Surgical Wounds 8. Skin Tear with Skin Present 9. Skin Tear without Skin Present 10. Stage 3 and 4 Pressure Ulcers 11. Venous Stasis Ulcers 12. Arterial Ulcers 13. Diabetic Ulcers 14. Complicated Surgical Wounds Secondary Order Sets These include anticipated supplies, routine DME, and associated secondary clinical pathway. There are no visit frequency orders or routine supply orders included on Secondary Order Sets to prevent duplicates. Order Sets for wounds also include the Preferred Protocols for treatment options. 1. Secondary Congestive Heart Failure 2. Secondary COPD / Chronic Respiratory 3. Secondary Chronic Diabetes 4. Secondary Stage 1 and 2 Pressure Ulcers 5. Secondary Uncomplicated Surgical Wounds 6. Secondary Skin Tear with Skin Present 7. Secondary Skin Tear without Skin Present 8. Secondary Stage 3 and 4 Pressure Ulcers 9. Secondary Venous Stasis Ulcers 10. Secondary Arterial Ulcers 11. Secondary Diabetic Ulcers 12. Secondary Complicated Surgical Wounds Clinical Pathways and Order Sets Page 2 of 46

5 Things to Keep in Mind When Following a Pathway Pathway Conventions to keep in mind 1. An Encounter is roughly equivalent to a visit. Some patients will be able to master the teaching faster than others, and conversely others will progress more slowly. On average, for most patients, one encounter will be one visit. 2. When documenting on interventions and goals, keep the following in mind: a. Documenting completed on an intervention means that the task has been completed during that encounter. It is a good idea to add any specific teaching or comments beside the intervention, so this will move to your note. b. Documenting not met for goals means that the goal is not presently met and is not expected to be met with any further interventions. c. If an intervention is partially accomplished, document what has been accomplished and leave the completion date blank. (i.e. patient instructed on signs of hyperglycemia today, which is all she is able to retain, continue with signs of hypoglycemia next visit). 3. Timely completion of visit documentation is essential. The visit documentation must be completed and synchronized in order for other staff to access the correct encounter. Paper documentation must be turned in and data entry must be accomplished timely in order to ensure that other clinicians have access to the most up to date clinical information. Clinical Pathways and Order Sets Page 3 of 46

6 Initial SOC Using an Order Set (RoadNotes) Initial SOC Using an Order Set (RoadNotes) (RN) 1. For Start of Care, Recertification or Change in Condition Follow up visit, perform skilled nursing assessment. (No change to current process at this time). 2. Attain signature on all required consents. 3. Complete all information in the Client Admission section. 3a. For a SOC, Click on Client Admission and select <New>. Complete all information including the Billable Diags, LOC, Team/Division, and MSP. 3b. For a Recert or ROC, do not complete Client Admission, instead, add the new Cert Period under f Clinical Pathways and Order Sets Page 4 of 46

7 Initial SOC Using an Order Set (RoadNotes) After all information is completed in Billable Diags, LOC, Team/Division, MSP is completed in the Client Admission tab, click [Save]. 4. Press the Order Set Icon and select the corresponding Order Set from the Order Set Icon on the tool bar across the top of the screen. Once the Client Admission section has been saved, click on the Order Sets Icon to add an Order Set. Clinical Pathways and Order Sets Page 5 of 46

8 Initial SOC Using an Order Set (RoadNotes) 5. Select the appropriate Primary Order Set for the patient Click on the Order Set for the primary presenting problem. 6. Review the Visit Order Strings, and edit them as necessary. Review the Order Strings to be sure they are as you would like. Remember to remove the initial string if intake has already put in the SOC visit. Use the scroll bar to view all of the Order Strings Clinical Pathways and Order Sets Page 6 of 46

9 Initial SOC Using an Order Set (RoadNotes) 7. Review Supplies and DME. Edit as necessary. Review the Supplies and/or DME that is preloaded for this Order Set. Remove only if necessary. 8. Review Preferred Protocols (attached to the Order Set as a Care Plan). Remove any portions of the protocol that are not applicable to the patient. Scroll further to see any of the pre loaded Preferred Protocols (FOR WOUND PROTOCOLS ONLY). Review and edit them, remove any of these interventions that you do not want to print to the 485. Clinical Pathways are pre loaded and should not be edited from this section. Make any changes under the Care Plans Icon. Clinical Pathways and Order Sets Page 7 of 46

10 9. When you have reviewed all of the orders, click [OK] to save your orders. Initial SOC Using an Order Set (RoadNotes) When you have reviewed all of the orders, click [OK] to save your orders 10. Select up to two (2) corresponding Secondary Order Sets for the patient, review and edit Supplies / DME and Preferred Protocols as per steps 4 through 9 above. Clinical Pathways and Order Sets Page 8 of 46

11 Initial SOC Using an Order Set (RoadNotes) 11. Go to VISIT ORDERS and review and edit the visit order strings to make sure the dates correspond to the appropriate weeks for the Cert Period/Episode. Save each one after making changes. Review the visit string orders (those added by the order set are in blue) and edit the start date to match the calendar as needed. 12. Go to Contacts and add a contact as usual, entering the type of visit, time and mileage, then press [Save]. Enter the Contact information and then click [Save] Clinical Pathways and Order Sets Page 9 of 46

12 Initial SOC Using an Order Set (RoadNotes) 13. When a Pathway is attached, the Pathway Button will become active. Press it and select the Primary Pathway and select the appropriate Encounter Number. When a Clinical Pathway has been attached, the Pathways button will be active. Click Pathways to begin documenting. 14. Select the Primary pathway (Secondary pathways are labeled as Secondary). Note if only one pathway is assigned, you will be asked to choose the Encounter. Choose the Primary Pathway using the drop down arrow. You will have the opportunity to choose the Secondary later. Clinical Pathways and Order Sets Page 10 of 46

13 Initial SOC Using an Order Set (RoadNotes) 15. Select the Encounter Number Select the Encounter Number 16. Document on all of the interventions assigned to the Encounter Number on the Interventions tab. The Clinical Pathways grid will appear. Document against all interventions assigned to the Encounter. Use completed, done or n/a to specify the intervention to the patient s condition. Use the Drop down in the column titled Encounter Date to denote that the Intervention was addressed. Clinical Pathways and Order Sets Page 11 of 46

14 Initial SOC Using an Order Set (RoadNotes) Work down the list of Interventions and document how you completed the assigned item or document specifics about the teaching. Use the Completion Date column to indicate that you provided the information to the patient. The Goals section represents how the patient receives the education or intervention. Switch to the Goals Tab and document the goals accomplished during the visit by adding the date completed (or not) to all interventions assigned to that encounter. When completed, switch to the Goals Tab. Clinical Pathways and Order Sets Page 12 of 46

15 Initial SOC Using an Order Set (RoadNotes) Look for the goals associate with the Encounter, mark them as Met or Not Met as appropriate. Remember that this means 100%, and if Not Met type in the Variance Reason. 17. If you have additional (secondary) pathways to document, click [Save] and chose the next pathway and encounter number Click [Save], the Pathway Selection box will appear, followed by the Encounter Selection Box, complete the documentation as above. Clinical Pathways and Order Sets Page 13 of 46

16 Initial SOC Using an Order Set (RoadNotes) Choose the Secondary Pathway using the drop down arrow. Select the Encounter Number Clinical Pathways and Order Sets Page 14 of 46

17 Initial SOC Using an Order Set (RoadNotes) Refer to Step 16 above for more detailed information Note that Interventions and Goals in the Secondary Pathways include ONLY elements specific to that disease process, so they are much shorter. Clinical Pathways and Order Sets Page 15 of 46

18 Initial SOC Using an Order Set (RoadNotes) 18. When you have no further pathways to document, then press the Profile Button and Select an the OASIS Profile, attach and document. Narrative information from each of the pathways will pull into the section titled Pathway Notes. When you have completed all Pathway documentation, then click the [Profile] button and select/attach the desired Profile. All of the documentation from the Clinical Pathway is automatically imported to the Clinical Pathway Notes section of the Profile. The Intervention is listed first, then the clinician s comments for Primary and all Secondary Clinical Pathways. Clinical Pathways and Order Sets Page 16 of 46

19 Initial SOC Using an Order Set (RoadNotes) 19. Complete all other sections applicable to the Client s Admission in the same manner as you have previously. Be sure to review the DME and Supplies sections and make any additions that may not be covered in the Order Set. Complete the rest of the documentation required for the Admission. Be sure to review the DME and Supplies to make any additions not included in the Order Sets. Clinical Pathways and Order Sets Page 17 of 46

20 Routine Visit Using a Clinical Pathway (RoadNotes) Routine Visit Using a Clinical Pathway (RoadNotes) (all SN staff) 1. Perform your routine nursing assessment. 2. Go to Contacts and add a contact as usual, entering the type of visit, time and mileage, then press (Save). Enter the Contact information and then click [Save] Clinical Pathways and Order Sets Page 18 of 46

21 Routine Visit Using a Clinical Pathway (RoadNotes) 3. When a Pathway is attached, the Pathway Button on the Contact will become active. Press it and select the Primary Pathway and select the appropriate Encounter Number. When a Clinical Pathway has been attached, the Pathways button will be active. Click Pathways to begin documenting. Choose the Primary Pathway using the drop down arrow. You will have the opportunity to choose the Secondary later. Clinical Pathways and Order Sets Page 19 of 46

22 Routine Visit Using a Clinical Pathway (RoadNotes) Select the Encounter Number Select the Encounter Number 4. Review all of the appropriate interventions of that visit, perform your interventions and teaching as assigned Document on all of the interventions assigned to the Encounter Number on the Interventions tab, mark the intervention as completed by adding the completion date. The Clinical Pathways grid will appear. Document against all interventions assigned to the Encounter. Use completed, done or n/a to specify the intervention to the patient s condition. Use the Drop down in the column titled Encounter Date to denote that the Intervention was Clinical Pathways and Order Sets Page 20 of 46

23 Routine Visit Using a Clinical Pathway (RoadNotes) Work down the list of Interventions and document how you completed the assigned item or document specifics about the teaching. Use the Completion Date column to indicate that you provided the information to the patient. The Goals section represents how the patient receives the education or intervention. When completed, switch to the Goals Tab. Clinical Pathways and Order Sets Page 21 of 46

24 Routine Visit Using a Clinical Pathway (RoadNotes) 5. Switch to the Goals Tab and document the goals that accomplished during the visit by adding the date met (or not met) for all goals assigned to that encounter. Remember, completed goals means all aspects have been met. If you are recommending that the goal continue, do not mark it as met/not met, leave it blank and document the reason for the variance. Look for the goals associate with the Encounter, mark them as Met or Not Met as appropriate. Remember that this means 100%, and if Not Met type in the Variance Reason. 6. If you have additional (secondary) pathways to document, press [Save] and chose the next pathway and encounter number, repeat Steps 4 and 5 as above. Click [Save], the Pathway Selection box will appear, followed by the Encounter Selection Box, complete the documentation as above. Clinical Pathways and Order Sets Page 22 of 46

25 Routine Visit Using a Clinical Pathway (RoadNotes) Choose the Secondary Pathway using the drop down arrow. Select the Encounter Number Clinical Pathways and Order Sets Page 23 of 46

26 Routine Visit Using a Clinical Pathway (RoadNotes) Note that Interventions and Goals in the Secondary Pathways include ONLY elements specific to that disease process, so they are much shorter. Clinical Pathways and Order Sets Page 24 of 46

27 Routine Visit Using a Clinical Pathway (RoadNotes) 7. When you have no further pathways to document, then press the Profile Button and Select an the SN Routine Pathway Visit Note Profile, attach and document as usual. Narrative information from each of the pathways will pull into Section 39, titled Pathway Notes. When you have completed all Pathway documentation, then click the [Profile] button and select/attach the desired Profile. All of the documentation from the Clinical Pathway is automatically imported to the Clinical Pathway Notes section of the Profile. The Intervention is listed first, then the clinician s comments for Primary and all Secondary Clinical Pathways. Clinical Pathways and Order Sets Page 25 of 46

28 Routine Visit Using a Clinical Pathway (RoadNotes) 8. Section 41 Visit Narrative / Scorecard Summary is a blank section for you to periodically document a summary of the patient s progress toward meeting their goals. Any information entered here will potentially be part of the Scorecard report sent to the physician. Narrative Section can be used to report on the disease specific scorecard. Clinical Pathways and Order Sets Page 26 of 46

29 Initial SOC Using an Order Set (HomeWorks) Initial SOC Using an Order Set (HomeWorks) (RN, Clerical Staff Entering a SOC) 1. Fill in the information in the Admission section. 2. Select the corresponding Order Set from the Order Set Icon on the tool bar across the top of the screen. Complete the admission tab and click on the Order Set Icon. Clinical Pathways and Order Sets Page 27 of 46

30 Initial SOC Using an Order Set (HomeWorks) 3. Select the appropriate Primary Order Set for the patient Choose the appropriate Primary Order Set for the patient s condition 4. Review the Visit Order Strings, and edit them as necessary. Review the Order Strings to be sure they are as you would like. Remember to remove the initial string if intake has already put in the SOC visit. Use the scroll bar to view all of the Visit Order Strings Clinical Pathways and Order Sets Page 28 of 46

31 Initial SOC Using an Order Set (HomeWorks) 5. Review Supplies and DME. Edit as necessary. Review the Supplies and/or DME that is pre loaded for this Order Set. Remove only if necessary. 6. Review Preferred Protocols (attached to the Order Set as a Care Plan). Remove any portions of the protocol that are not applicable to the patient. Scroll further to see any of the pre loaded Preferred Protocols (FOR WOUND PROTOCOLS ONLY). Review and edit them, remove any of these interventions that you do not want to print to the 485. Clinical Pathways are pre loaded and should not be edited from this section. Make any changes under the Care Plans Icon. Clinical Pathways and Order Sets Page 29 of 46

32 Initial SOC Using an Order Set (HomeWorks) 7. When you have reviewed all of the Orders and made your edits, click the [OK] Button. When you have reviewed all of the orders, click [OK] to save your orders 8. If needed, you can select up to two (2) corresponding Secondary Order Sets for the patient, review and edit Supplies / DME and Preferred Protocols as per instructions 3 through 8 (above). Clinical Pathways and Order Sets Page 30 of 46

33 Initial SOC Using an Order Set (HomeWorks) 9. Go to VISIT ORDERS and review and edit the visit order strings to make sure the dates correspond to the appropriate weeks for the Cert Period/Episode. Save each one after making changes. Once the Order Sets are attached, Click on the Visit Orders Icon and edit the Start and dates for the order string (if necessary). Add orders for any other discipline. 10. Go to Contacts and add a contact as usual, entering the type of visit, time and mileage, then press [Save]. Enter the Contact Information as usual, then click [Save]. Press the Clinical Pathways Button Clinical Pathways and Order Sets Page 31 of 46

34 Initial SOC Using an Order Set (HomeWorks) 11. When a Pathway is attached, the Pathway Button will become active. Press it and select the Primary Pathway and select the appropriate Encounter Number. If there are multiple clinical pathways attached, use the drop down to choose the primary clinical pathway first (secondary pathways are labeled secondary ). Once you have selected the pathway, click [OK] Clinical Pathways and Order Sets Page 32 of 46

35 Initial SOC Using an Order Set (HomeWorks) Highlight the correct encounter number and click [OK]. Hint: The system will default to the first Encounter Number showing as completed. 12. Document on all of the interventions assigned to the Encounter Number on the Interventions tab. Clinical Pathways and Order Sets Page 33 of 46

36 Initial SOC Using an Order Set (HomeWorks) 13. Switch to the Goals Tab and document the goals accomplished during the visit by adding the date completed (or not) to all interventions assigned to that encounter. Use the drop down to select the met or not met date. Switch from Interventions to Goals/Outcomes Tab Click [Save] to continue documenting on Secondary Pathways. 14. If you have additional (secondary) pathways to document, press save and chose the next pathway and encounter number, repeat Steps 13, 14, and 15 as above. Clinical Pathways and Order Sets Page 34 of 46

37 Initial SOC Using an Order Set (HomeWorks) Clinical Pathways and Order Sets Page 35 of 46

38 Initial SOC Using an Order Set (HomeWorks) Notice that Secondary Pathways may not have goals assigned to every encounter, but review each visit and document those that are met 15. When you have no further pathways to document, then press the Profile Button and Select an the OASIS Profile, attach and document. Narrative information from each of the pathways will pull into the section titled Pathway Notes. You can attach your profile directly from this screen. If you forget, you can still save here and attach from the contacts also. The computer will blink as it moves your information from Pathways to load into your note, this is normal. Clinical Pathways and Order Sets Page 36 of 46

39 Initial SOC Using an Order Set (HomeWorks) Narrative documentation from all of the Clinical Pathway interventions (Primary and Secondary) will be automatically added to the SN OASIS in section 94 on the SOC version. (Previously Additional Notes ). 16. Complete all other sections applicable to the Client s Admission in the same manner as you have previously. Be sure to review the DME and Supplies sections to add any items that were not included in the Order Set. Clinical Pathways and Order Sets Page 37 of 46

40 Routine Visit Using a Clinical Pathway (HomeWorks) Routine Visit Using a Clinical Pathway (HomeWorks) (All SN Staff and/or Clerical Staff Entering the Data from a Routine Visit) 1. Fill in the information in the Admission section. 2. Go to Contacts and add a contact as usual, entering the type of visit, time and mileage. Enter the Contact Information as usual. Press the Clinical Pathways Button Clinical Pathways and Order Sets Page 38 of 46

41 Routine Visit Using a Clinical Pathway (HomeWorks) 3. When a Pathway is attached, the Pathway Button on the Contact will become active. Press it and select the Primary Pathway and select the appropriate Encounter Number. If there are multiple clinical pathways attached, use the drop down to choose the primary clinical pathway first (secondary pathways are labeled secondary ). Once you have selected the pathway, click [OK] Clinical Pathways and Order Sets Page 39 of 46

42 Routine Visit Using a Clinical Pathway (HomeWorks) Highlight the correct encounter number and click [OK]. Hint: The system will default to the first Encounter Number showing as completed. 4. Review all of the appropriate interventions of that visit, perform your interventions and teaching as assigned Document on all of the interventions assigned to the Encounter Number on the Interventions tab, mark the intervention as completed by adding the completion date. Use the drop down to select the completion date. Document any narrative information for the assigned interventions here. Clinical Pathways and Order Sets Page 40 of 46

43 Routine Visit Using a Clinical Pathway (HomeWorks) 5. Switch to the Goals Tab and document the goals that accomplished during the visit by adding the date met (or not met) for all goals assigned to that encounter. Remember, Completed Goals means all aspects have been met. If you are recommending that the goal continue, do not mark it as met/not met, leave it blank and document the reason for the variance. Use the drop down to select the met or not met date. Switch from Interventions to Goals/Outcomes Tab 6. If you have additional (secondary) pathways to document, press [Save] and chose the next pathway and encounter number, repeat Steps 2 through 5 above. Clinical Pathways and Order Sets Page 41 of 46

44 Routine Visit Using a Clinical Pathway (HomeWorks) Clinical Pathways and Order Sets Page 42 of 46

45 Routine Visit Using a Clinical Pathway (HomeWorks) Notice that Secondary Pathways may not have goals assigned to every encounter, but review each visit and document those that are met 7. When you have no further pathways to document, then press the Profile Button and Select an the SN Routine Pathway Visit Note Profile, attach and document as usual. Narrative information from each of the pathways will pull into Section 39, titled Pathway Notes. You can attach your profile directly from this screen. If you forget, you can still save here and attach from the contacts also. The computer will blink as it moves your information from Pathways to load into your note, this is normal. Clinical Pathways and Order Sets Page 43 of 46

46 Routine Visit Using a Clinical Pathway (HomeWorks) Select the SN Routine Pathway Visit (8) and click [Attach] Fill in the new streamlined Nurses note, there are many enhancements to speed this along. Note that all of the interventions listed in the pathways are now automatically placed in Folder #39 with your documentation beside Clinical Pathways and Order Sets Page 44 of 46

47 Routine Visit Using a Clinical Pathway (HomeWorks) 8. Section 41 Visit Narrative / Scorecard Summary is a blank section for you to periodically document a summary of the patient s progress toward meeting their goals. Any information entered here will potentially be part of the Scorecard report sent to the physician. Narrative Section can be used to report on the disease specific scorecard. Clinical Pathways and Order Sets Page 45 of 46

48 SOC or Recert with Paper Documentation SOC or Recert with Paper Documentation 1. The nurse completing a SOC, ROC, change of condition or Recert visit using paper documentation should have a copy of each Primary and each Secondary Clinical Pathway available to them during the visit. Offices may wish to provide nurses with multiple copies of each pathway, or incorporate a copy with each paper Admission /Resumption of Care Pack and each Recert / Change of Condition Pack in their office. The SN should have access to all Clinical Pathways. SN should select the appropriate Primary Pathway and any Secondary Pathways. SN should review each Pathway and document any notes and any interventions for Encounter 1 or Every Encounter. Including any notes and date completed. Initial and date any met or unmet goals for both the Primary and Secondary Pathway(s). Example: ASSESSMENTS Clinician to notify physician for SBP>160 or <90, DBP>90 or <60, HR>100 or <60, RR >24 or < 14, T >100.0 < 96 (oral) EVERY Encounter - not needed, VS WNL 10/1/09 NN, RN Assess SpO2 via pulse oximetry PRN, alert physician for values less than 92% at rest. EVERY Encounter - WNL 95% 10/1/09 Assess current activity and tolerance levels, ability to perform ADLs/IADLs, and level of assistance needed. Evaluate ability to maintain ADLs/IADLs. Encounter 1 - Pt requires assist with transfers and ADLs for bathing 10/1/09 NN, RN Assess level of dyspnea RPD /Exertion RPE scales with activity and at rest, note change in status. EVERY Encounter - completed 10/1/09 NN, RN Assess circulatory/cardiac status: VS; heart rate/rhythm; weight, edema; note change in status. EVERY Encounter - Completed, initial assessment 10/1/09 NN, RN Assess barriers to care (financial, cultural, cognitive, caregiver, environment, other). Encounter 1 - no barriers to care noted 10/1/09 NN, RN Assess environmental risk factors and recommend modifications, as appropriate. Encounter 1 instructed to remove the throw rugs in front of the bathtub, caregiver to complete this task 10/1/09 NN, RN 2. The assessment nurse should return the paper documentation for the OASIS, any Primary and Secondary Pathway(s) and Care Plan elements to the office within 24 hours of the assessment for the designated SCC to enter the information onto the Clinical Pathway grid. This will help make sure that the clinician scheduled for the next visit gets the appropriate pathway. Clinical Pathways and Order Sets Page 46 of 46