Rehab Notes Management System

Transcription

1 Rehab Time The Rehab Time module is integral to determining staff productivity and practice profitability. It is designed to function as a time clock. Each staff member simply logs in and punches in/out when they arrive at/leave the practice each day. The data from these time punches is used to calculate the productivity reports and the practice logs Once the staff member has logged in, using their own user id and password, they click the PUNCH IN button to indicate their arrival time. Likewise, they click the PUNCH OUT button to indicate their departure time. They should also select the discipline they will be performing, if their default discipline is not correct.

2 Functions The Rehab Director has access to the MANAGEMENT option on the pull down menu. In this screen the Rehab Director can add missed punches or edit erroneous punches. A Punch Report is also available for a selected Date Range.

3 Rehab Notes The Rehab Notes system is designed to allow a Rehabilitative Therapy practice to manage information related to patient evaluation, assessment, treatment and billing. It allows the data entered in this module to interface to the Minimum Data Set (MDS) system, to Care Plans and to Billing. It also provides extensive reporting to track productivity and profitability. The system is designed so the Rehab staff only has to enter their routine daily information. The required reports and interfaces are then produced from this data, therein reducing a significant quantity of redundant data collection. Census Integration A resident must be present in the Census system prior to entering data in Rehab Notes. If a resident s census information is incorrect it will adversely affect the Rehab information. Entering Data The process of entering data can be broken down into the following general steps: 1. Choose a Discipline 2. Choose a Form 3. Choose a Patient 4. Choose an Activity Date 5. Enter the Information 6. Print the Form Choosing A Discipline Choosing a Discipline To choose a discipline, select the appropriate button on the Therapy menu. The Evaluation, Daily Notes, Weekly Notes, Summaries, Orders and Care Plans for each discipline are located within these sections.

4 Choosing a Form Choosing a Form To choose a form, select the appropriate button on the Therapy Forms menu. To access a form click the button for that form. You will then be prompted to select the patient for whom you wish to enter information. The Update Payor Status button allows you to maintain information regarding who will be paying for the patient s treatment. Choosing a Patient Choosing a Patient Once you have chosen a form, a list of all active patients will automatically appear. This list is in alphabetic order. If the list does not appear, log into the Census module and click the Generate button. If you need to update a discharged patient, click the options button, enter a date range when the patient was in-house and click the Refresh button. Highlight the patient you wish to select and click OK

5 Choosing an Activity Date Rehab Notes Choosing Activity Dates To update an existing record, highlight the desired date and click the Edit Button. To enter a new record, click the New Button. When entering new records you should choose the date on which the service was actually performed. Click the Exit Button to leave this screen without entering data. Entering Information (Understanding the Forms) We will use the evaluation form to illustrate the use of various types of data fields and control functions. The Evaluation form must be completed before any other forms can be completed. Typically, the Evaluation is completed, then a series of Daily Notes, then Weekly Progress Notes. Every 30 days a Monthly Summary is completed and, finally, a Discharge Summary. It is important that a Discharge Summary be completed, as this indicates to several reports that the patient is off the caseload. Screen Functions Grayed Out Boxes contain information that is being drawn from other sources, such as Census. This data may not be altered in this screen. Drop Down Boxes Fields with arrows at the right side contain a predefined list of choices. These choices are maintained in the Look Ups module and may only be altered by a supervisor.

6 Screen Functions Text Boxes The larger, open fields are text boxes. These fields allow you to enter free text. Text boxes with scroll bars to their right allow you to enter more data than can displayed in the box on the screen. Some text boxes have a restriction on the amount of data you may enter. When you reach this limit the screen will not allow you to type further. These restrictions are due to limits on the available print space on certain forms and reports. Screen Functions Sliders These controls allow you to enter a numeric value, such as a FIM score, by sliding the indicator to the appropriate stopping point. As you slide the indicator the related number and description will be displayed. Check Boxes These fields are used to indicate True/False values. A check mark indicates that the condition exists. A blank box indicates that it does not.

7 Screen Functions Radio Buttons These controls allow you to enter a numeric value, such as a frequency or duration of time. You can either click in the box and type the value or use the arrows to increase or decrease the value in increments of 1. Typically, the fields accepts a limited range of values. Navigation On multi-page forms, such as Evaluations, use the arrow buttons to move from page to page. The current page number is displayed Screen Functions Print Click the Printer icon to print the current form. Most forms give you the option to preview the report prior to printing. Delete Click the Trash Can icon to delete a record. You will be prompted to confirm this choice. Access Forms You can access Daily Notes from within the Eval by clicking the Start Daily Note button.

8 Updating Payor Status Update Payor Status When entering an Eval it is important to verify the correct Payor Status for Rehab services. To do this click the Update Payor Status button. This option can also be found at the bottom of each discipline menu. This information is essential to accurate RUG, billing, Invoice and Practice Log creation. Update Payor Status On the Rehab Payors form you can Edit, Delete or add a New Payor Status. Whenever you choose to Add or Edit a Payor Status the lower portion of this form will display. Indicate the Payor Type and effective date. If the payor is Insurance, please indicate the carrier. If the payor is Medicare please indicate Part A or Part B. Click the Accept button to update the Payor Status.

9 Closing Out the Evaluation and entering Service Dates Closing Evaluations When you enter an evaluation, the final screen is left blank. This screen is linked to block 21 on the 700 form. When it is time to complete the first monthly summary, access the Service Dates page of the Eval and enter the required information. Then, print page 2 of Evaluation and place it in the patient chart. Likewise, when completing monthly summaries, the Status at end of Period should be left blank until the end of that 30 day period, then complete it. Care Planning from the Evaluation Form Care Planning You can complete the Care Plan by entering the Deficits, Long Term Goals, and Short Term Goals in the Evaluation Form. Then check the boxes for the treatment plans you plan to pursue. Be sure to enter the Deficit descriptions and to check the boxes for the Treatments to be performed.

10 Care Planning Be sure to enter both Short Term and Long Term Goals. These Goals will also carry over to the first Weekly Notes. Care Planning Click the Care Plan button at the bottom of the screen. You will be prompted to accept the information you entered in each of these sections. If you opt to select the Deficits, Goals and Treatments from the Evaluation, this information will be used to create the Rehab component of the resident care plan.

11 Care Planning Select the Short Term Goals. Care Planning Select the Long Term Goals.

12 Care Planning Select the Treatments. Please note, there is a text box at the bottom of the Treatments Section that allows you to specify procedures other than those in the check boxes. This should be done while completing the Evaluation. Accessing & Editing the Care Plan Care Planning You can access the Care Plan module from with the Rehab Notes module by clicking the Care Plan button within each of the discipline menus. Use the Care Plan module to edit, discontinue or remove the Rehab care plan you have created. You can also enter additional deficits, goals and treatments and approaches. You can print the Care Plan from here, as well.

13 Care Planning Within the Care Plan module you can enter information manually or select information from pre-built libraries. See the Care Plan Manual for additional information. Printing a Care Plan Printing Care Plans Select Care Plans from the PT, OT or SLP menu. Select the resident for whom you want to print. Select Care plan Cover Sheet or Care Plan Detail.

14 The Care Plan Cover Sheet Care Plan Cover Sheet This report displays basic demographic information, diagnosis codes and a list of the resident s care plan problems/deficits. Care Plan Form with Signature Lines Care Plan Detail This form shows the resident s problems, goals, and approaches, along with the discipline responsible for implementing each. This form can be printed in it s entirety or for just a single problem.

15 Printing a PT Evaluation Forms Printing Evaluations To print an evaluation click on the printer icon at the bottom of the screen. To print a generic form select Standard Evaluation Form. To print the 700 form select Medicare Evaluation Form. If you only need to print the second page, unclick the Page 1 box. If you want to view the report on the screen prior to printing click the Preview box, then click the Print button. Standard Evaluation Page 1 This is a generic evaluation form, acceptable to most commercial insurance companies and fro self paying residents.

16 Standard Evaluation Page 2 The second page of the Standard Evaluation also displays FIM scores and special equipment requirements. Medicare Evaluation Page 1 This report is also known as the 700 Form. It contains all evaluation data required by the Medicare program.

17 Medicare Evaluation Page 2 The second page of the 700 Form includes FIM scores and equipment requirements. It also contains block 21, for entering the resident status at the end of the first month of treatment. Exiting the Evaluation Form Exiting the Evaluation Click the EXIT button at the bottom of the Evaluation screen. You will be asked if you want to do another evaluation. Click the NO button to exit. Click the YES button to select another resident.

18 Physician Orders Physician Orders Page 1 This section allows the treating physician to enter his/her instructions for providing Rehab services to the resident. Page 1 is for entering the objectives of the therapy. Physician Orders Page 2 The second page is for entering the recommended treatments.

19 Physician Orders Page 3 The third page is for entering the recommended frequency of treatments. This page also projects RUG levels based upon ordered therapies. Daily Notes Daily Notes This is, perhaps, the most important screen in the system. On this screen the therapists enter the number of minutes for each modality performed each day. This information is used on virtually ever other document generated by this software. There is a section for standard treatments and dropdown boxes for selecting other treatments.

20 Daily Notes Units are automatically calculated, based on minutes, but you may override these amounts. Check the Group box for any treatment that was delivered in a group setting. This is important for calculating RUG levels and productivity. The therapist(s) who deliver the treatments must enter their user names. Daily Notes The second page of the Daily Note allows you to enter FIM scores, equipment, comments, ambulation and balance information. From either page you can open an additional Daily Note, a Weekly Note, or a Monthly/Discharge Summary.

21 Daily Notes When you open an additional Daily Note, a Weekly Note, or a Monthly/Discharge Summary, you will be prompted to select the date of the document you want to view/edit. You can also add a new record by clicking the ADD button. To print the Daily Note click the printer icon. Printing Daily Notes Printing Daily Notes When you click the printer icon you will be prompted to select the date, or range of dates, you want to print. You can also opt to print a detailed list of the treatments provided on those dates.

22 Daily Progress Note Daily Progress Notes This report displays the FIM scores, equipment and therapist s comments for that days treatment. Detail Patient Record Detail Patient Record This report is a detailed log of all modalities performed for the resident on the date(s) requested. This report can also be requested from the Reports Menu.

23 Weekly Notes Weekly Notes This form is used to summarize resident progress on a weekly basis. Select the begin and end dates for this note. The Goals are pulled from the Eval OR the most recent Weekly Note. You can: Edit the Daily Notes that feed this Weekly Note Enter Comments, Change Treatment Frequency. You can print all comments for the week selected. Printing Weekly Notes Printing Weekly Notes To print this form click on the printer icon, then select the weekly note you want to print.

24 Weekly Note Form Printing Weekly Notes The printed form show the resident s functional levels, their updated goals and the therapist(s) comments. Monthly Summaries (701) Monthly Summaries The Summary screen is used to update a resident s progress at 30 day intervals and to gain recertification for continued treatment for Medicare residents. This form is also used to document a resident s status upon their discharge from Rehab treatment. Check the appropriate box. Update all open fields except for Functional Level at End of Period. This should be completed at the end of the 30 day period. Enter Recert Dates for Monthly Summaries. Remember to enter the Service Dates when completing the Functional Level field.

25 Printing Summary Forms Discharge Summary Monthly Summary

26 Administrative Time Administrative Notes It is important to document time spent on non-resident tasks. This information is used to create Practice Logs and Facility Invoices. Certain tasks may be billable to the nursing facility. You can indicate these in the Lookups Module. Select the therapist, enter a date and click the Add button. Enter minutes for each task performed. To the left you can look up Notes by therapist and date. Screens Screens It is important to document time spent screening residents. This information is used to create Practice Logs and Facility Invoices. Certain tasks may be billable to the nursing facility. You can indicate these in the Lookups Module. Select the therapist, enter the resident name, date, disciplie and payor and click the Add button. Enter minutes for each task performed. To the left you can look up Notes by resident and date. You can also schedule the next screen for a resident.

27 Printing the Practice Log Practice Log This report provides a one week snapshot of productivity and profitability for a department, a discipline or an individual. It is important that all employee time, all daily notes, all Administrative Notes and all Screens are entered properly. It is also crucial that all CPT rates, service rates and average pay rates are entered properly in the Lookups Module. Practice Log The body of the log shows detail of the residents seen for the week selected and time spent on administrative tasks and resident screens.

28 Practice Log The summary section provides information on staff productivity and projected profitability. Pull Down Menus Daily Notes / Weekly Notes / Summaries / Evaluations Pull Down Menus The data collection forms can also be accessed by selecting the appropriate pull down menu at the top of the display. Instead of selecting the Discipline, then the Form, you can select the Form, then the Discipline. You can also access the Reports menu and certain maintenance Options. You can also exit the software from this location.

29 Options / ICD9 Codes / Doctors Options All fields within the Rehab Notes system that have drop down selection options are maintained in the Lookups Module. You control the contents of these files. Two of these files, ICD9 Codes and Doctors, can also be accessed within Rehab Notes. Managing ICD9 Codes ICD9 Codes All diagnoses that have a check mark in the Rehab column will be available within the Rehab Notes system. All ICD9 codes are in this file.

30 Managing Doctor Codes Doctor Codes Click on the doctor you want to update, then click the EDIT button. Click the ADD button to enter a new doctor. Please be sure that this physician has privileges at the nursing facility. Doctor Codes Enter the doctor s name, last name, then first. Click the OK button.

31 Doctor Codes Enter the doctor s information. Be sure to include the UPIN number and the Medicaid Provider number if they are available. If the doctor has admitting or attending privileges please check those boxes. Otherwise you will not be able to use this doctor in that fashion in the Referral and Census modules.

32 HELP The system manuals can be found in the HSC folder on your server. There are Files describing the functions and procedures for all HSC applications you have licensed. The files are stored in Adobe PDF format. These manuals can be printed and bound. They can also be key word searched. Under the help option on your pull down menu there is an option titled About. This screen displays the version and license information for the module you are using.

33 Reports Reports There are a variety of reports provided to help you manage your practice. There are reports for Billing, Productivity and Caseload management. Click on the report you want to print within the Reports button or on the Reports drop down menu. Report Filtering Options Reports Options Most Rehab reports can be selected by: Date Range, Discipline or Individual Most Rehab reports can be sorted by: Name, Unit, Payor, Discipline or Resident Number Some reports can be exported to an Excel format. All reports can be previewed prior to printing.

34 Sample Reports Billing Log Detail Patient Record

35 Treatment Summary Treatment Summary by CPT Code

36 Daily Productivity Summary Rehab Notes RUG Level Estimator

37 RUG Level Target vs. Actual Comparison Rehab Notes Part B Fee Tracking Report

38 Therapy Caseload Treating Diagnosis Report

39 Therapy Orders Report Summaries Due Report

40 Recertifications Due Rehab Notes Facility Invoices

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