CLINICAL MANAGEMENT - HIS

- There are three options after saving initial intake; the user can either go to the newly added patient’s profile, start a new intake, or go back to the home page.

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PATIENT'S PROFILE

The first thing that will show right after clicking the blue button is the Patient summary and the calendar.

Patient Summary

- On the left side of the page is summarized information of the patient, from the necessary information down to the status of the Hospice Item Set (HIS).
- On the right side is the Calendar. This is where the user can easily plot or post a visit, create a note, create an order, and add supplies. The user can also post an IDT here.

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Care Summary

- The user may access the care summary at the middle left, beside the Patient Chart.
- The user has the option to print it or to expand the items to view more details.
- The user can also set the date on the upper left side with “As of” filter to narrow down the list of documents that will show.

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PATIENT CHART

The user may access the Patient chart by pointing the mouse at the upper right of the Patient Summary.
Clicking the Patient Chart will show multiple items linked to the patient.

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Face Sheet / Admission Info

The user has an option to update the necessary information about the patient. The user also has an opportunity to print it.
If the user accidentally re-admitted a patient, the user can delete the admission by clicking the "Delete Admission" button and providing the password to confirm the action.

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Admission Source and Referral Source

- - The user needs to add the Admission and Referral Source of the patient manually by clicking the “Edit” button at the upper left.
  - The patient's Admission Source will link to the Billing once the user processes a claim of the patient.
  - The Referral Source will be used for the agency's reports.

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Emergency Plan

- - The user can fill the patient's Emergency Plan for compliance.
  - The user has an option to copy the details from another admission.
  - The user can also view the summary of the Patient's EPP Instructions and print it.

Note: The Emergency Contact(s) is for viewing only. If the user wants to update this, the user will have to go to the patient's contact list.

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Patient Info

Legal Name Field
- - The Medicare card has a standard maximum number of characters allowable for display. This is to ensure that the name placed is precisely the same from the Medicare card. The name entered will be considered the legal name of the patient.
  - Max Characters for the First Name is 12; and 18 characters for the Last Name.
  - This will be used on the NCA-HIS and DC-HIS and when the user generates a bill for the patient.

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Race/Ethnicity
- - The user needs to fill this out manually on the Info page. This will then auto populate on the NCA-HIS.

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Eligibility Check
- - This is where the user can check if the patient is eligible for Hospice Care.

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Exclude in CAHPS Survey
- - This field will be used for the CAHPS (Consumer Assessment of Healthcare Providers and Systems) Survey. This means that the patient or caregiver does not want disclosure in case of patient's death.

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NCA-HIS

- Nursing Comprehensive Assessment - Hospice Item Set
- The user can find this on the patient chart below Admission Info.
- Only Data Soft Logic has a user-friendly feature wherein the admitting discipline can fill out the NCA and HIS at the same time.
- This will help the field user a lot on their documentation process.
- To easily distinguish the HIS items from the NCA items, the latter has a grey background.

- NCA-HIS Process
  - Save, Validate, Lock, and Verified completes the process.
  - Validating the document will give the user a popup on the bottom left. This will guide the user if there are fields that were missed.
  - Note that the Validate button is disabled if the agency's NPI and CCN are not updated. This can be done by going to Admin » Agency » Agency Info.

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- For Verification by:
  - - The Admitting discipline must be listed here.
    - The user may type in manually the name on the field.

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Comorbidities (on page 2)
- - The user can add comorbidities through NCA. All the user needs to do is to click “Add New,” then the user can type in a specific diagnosis or the first few letters of the diagnosis which will show options on the dropdown.

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Pain Assessment (on page 4)
- - This is where the user can drag the number to where the wound is located by clicking the image on the right side.
  - The Wong-Baker Scale will help the user determine the level of pain that the patient has.

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Prognosis Guideline LCD (on page 8)
- - The user needs to check the checkbox on the left side of the Prognosis Guideline.
  - If the patient’s diagnosis is not on the list, the user must choose all diagnosis so that the LCD pages will extend to the last Section.

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Care Problems (on page 8)
- - Any Care Plan Problems the user fills out will auto-populate on the IPOC.

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Symptoms Management Pathways
- - Whenever the text area is clicked, a button will show up with a menu for Symptom Management Pathways.
  - Clicking the menu Symptom Management Pathways will display a popup.
  - Double-clicking an item will populate the content of the intervention's column on the selected text area.

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Karnofsky Scale (on page 9)
- - The lower the score, the lower the survival for most illnesses.

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Assigned discipline signature (page 9)
- - Z0400. Signature(s) of Person(s) Completing the Record
    - - All assigned discipline that was added through intake will show up on this field.
      - The user may remove the names by clicking the ”Remove” option, or h the user may add another by clicking the ”add new.”
  - Z0500 Signature(s) of Person Verifying Record Completion
    - - The signature of the discipline who verified the HIS.
      - Do not forget to set the date of the signature.

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- HIS Summary
  - It will show the user all the HIS fields.

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- NCA Summary
  - - Only the NCA Field will show up.

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History
- - This will show a list of activities happened on the NCA-HIS.

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- Copy Most Recent
  - - This will allow the user to update the documents for non-key fields if there are some changes.
    - A confirmation popup will show right after clicking the button before proceeding with the update.

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Version Control #: DSL2019-2.2

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