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Clinical Long Term Care Software
Discipline Assessment
Discipline Assessment is a very complete and comprehensive assessment tool
that the user can customize to his particular needs. Once the assessment is complete the user can
update the resident's MDS with the press of a button.
User Definable Tables include the Assessment Master and the Assessment Type
Codes.
Assessment Master allows the user to define the categories he wishes to assess.
Fourteen of the categories have already been defined.
Assessment Type Codes are the specific sub-categories the user will be
evaluating within the master categories. These codes are under the user's control and can be
modified to suit particular needs.
Reports include the Resident Assessment, which is a twenty-five page printout
with the pre-defined categories and any categories the user has added.
INSERVICE TRACKING
User Definable Inservice Categories (Patient Care, Safety Inspections, etc.)
User Definable Class Codes (OBRA, OSHA, etc.)
User Definable Inservice Tracking Table - which maintains the description,
Category, Class, number of minutes, required/voluntary, and the dates scheduled. Allows the user
to develop and maintain a master inservice schedule and define allowable and mandatory annual
hours.
Data Entry starts with Inservice Tracking Code and Inservice Date, and allows
quick entry of employees that attended the Inservice Meeting.
Inquiry Programs by Inservice Code and Date allow the user to display
statistics on each inservice, such as who attended - their ID's and social security number.
Inquiry Programs by Employee - display history of an employee's inservice
attendance, allow for compliance testing, and quickly provide total accumulated inservice hours
for a specific date range.
Attendance Lists by Inservice Code/Date.
Inservice Summary Lists for selected date range, category, and class, showing
hours and employee counts.
Employee Inservice History - Detail and Summary formats.
MEDICAL RECORDS
User Definable Tables - include Frequency Codes, Drug Codes, and
Medical Records Codes. Medical Record Codes provide the ability to set up codes, which trigger
additional medical record items based on user-defined frequencies.
Medical Records - provides the ability to define an unlimited number of medical
record codes per resident/patient. Recurring records can be easily generated for creating 'tickler'
schedules for future dates. Items which are automatically triggered based on definitions in the
Medical Records Codes are automatically generated by the system. Records can also be generated via
templates defined for the facility. The screen allows for the entry and review of medical record
codes, dates, values (such as temperature, weight, blood pressure, etc.) and comments. It also
allows weight tracking analysis in accordance with the Federal Register guidelines indicating a
significant change has occurred.
Medical Records Print and Display - provides viewing and reporting of medical
record data by resident/patient and by medical record codes. Statistical information can be extracted
by medical record code as needed. Residents whose weights (or other numerical code, i.e., blood
pressure) have varied by more than a user defined percentage amount can be printed.
Physicians Orders Entry - provides the ability to enter diet, lab, medication,
treatment, notes, and other orders for each resident/patient. Order information is entered as
free-form text, along with frequency codes as needed, and drug codes for medication records. As drug
codes are entered, the resident allergy data is cross-checked and a warning will be prominently
provided. In addition, if an anti-infective medication is entered, an infection report will be
initiated and automatically prompted for completion.
Print Physicians Orders - prints a hard copy of the orders to the printer.
Individual types can be printed separately (diets, lab, med sheet, treatment, notes, etc.) or a
comprehensive report can be printed. MARs, and TARs, are also available for printing monthly
physicians orders. The TB Screening is available for residents, as well as volunteers and
employees.
COST/OUTCOME MEASUREMENT
User Definable Parameters - define Cost per Hour required for
Licensed, Unlicensed, and Therapy staff, as well as an overhead factor that will be applied to
cost. There are also fields to establish a scale of hours to determine resident's level of care,
and staffing requirements for day, evening, and night shifts.
User Definable Tables - define Categories and Conditions by Category, and
allow assignment of Licensed, Unlicensed and Therapy minutes for each condition. The conditions
are cross-referenced to the MDS, which gives the capability to generate a preliminary MDS from
the Health Assessment.
Health Assessment Data Entry - for quick and easy assessment of
resident conditions. Choose from resident profiles entered through the admissions module. When
assessing the current condition, goal conditions and goal dates can be entered for outcome
measurement results.
Print Resident Assessments - shows the conditions by category, with an
extension of the time and cost for each item assessed, and a total time and cost for the per
patient. Cost and overhead factors are applied using the parameters and category/condition tables.
Assessment Change Register - provides a log of changes to assessment conditions,
by patient, for any date range selected. This tool can be used as a daily or weekly status report of
changes in condition.
Update MDS - provides the option to generate a preliminary MDS from the assessment
conditions that are cross-referenced. Full MDS and Quarterly MDS's can be generated from the most
current Health Assessment conditions as they apply.
Display, List, and Count Residents by Assessment Category and Condition. Options
are available to display count summaries only, or provide a detailed patient list for each condition.
Quality Review Report, Utilization Review Report and LN Progress Report are printed
as required. Each of these reports provides the ability to compare the resident's change in condition
from admit date to goals to discharge date, providing a tool to determine Outcome Measures for each
individual. Net change in minutes and cost is presented to show the total decrease in time and cost as
the resident's condition is improved by quality care.
Resident Roster - provides a spread-sheet like report, listing the resident
conditions, time and cost, with sub-totals by Medicare certified and uncertified sections, and average
times and cost by section.
Staffing Requirements Report - can be printed by Unit Location, with sub-totals
of time required for the Licensed and Unlicensed areas within each location. The sub-totals are further
broken down by shift requirements from the parameters table.
Census and Condition Summary - gives a neat one-page summary of total and average
time and cost by category.
Outcome Measure Averages - provides a tool to study the facility's average time
and cost, by assessment category, from admit date to discharge date.
Revenue/Cost Analysis - produces a register, by resident, showing total revenue
billed, total cost assessment, and net profit, for any selected date range.
Diagnosis Analysis - produces a summary by primary ICD-9 diagnosis code,
showing total revenue billed, total cost assessment, and net profit, for any selected date range.
Fiscal Year Summary - provides a monthly breakdown of times, costs, averages,
census information, and occupancy percentage, with sub-totals for the certified and non-certified
sections.
Care Plans
User Definable Care Plan Master - Structure is composed of Categories (you are
started with Approaches, Goals, Problems, and Etiologies) within RAP Codes plus several additional
categories. For each Category Type, the user can define up to 9999 items. A library is supplied;
the user can add to, change, and delete from this base library to customize the care planning needs
to your facility.
Care Plan Data Entry with display of RAP Triggered data for the Resident/Patient.
The ability to enter the care plan by choosing items from the pre-defined Care Plan library or create
custom entries for the Resident/Patient on the fly; and the ability to add these custom entries to the
Care Plan library.
Reports by Resident, including Care Plan Print, Problem Lists, Approach Charting.
Problem Date Reports and Goal Date Reports, as well as Unresolved Goals Reporting.
Display, List and Count Care Plans by RAP Code/Category/Care Plan Item.
Automatic Generate of Care Plans by RAP/Trigger Cross Reference, definable by the
user. Will allow the user to review, edit, and up-date care plans as well as create MDS-generated Care
Plans.
Minimum Data Set
Data Entry presents an exact facsimile of the MDS form for data entry. The user
can answer questions using the mouse to check boxes or select the proper number response from pull-down
menus. The Demographics walk over from the profile, reducing potential data entry errors and required
keystrokes.
Print MDS Assessments on plain paper and cannot be distinguished from the
traditional forms. Form text is printed from the Master File.
Triggered RAP Summary - shows the MDS items that triggered the RAP Category in
Trigger Legend format. These can be printed and displayed as well as a narrative style RAPs can be
"worked" directly from the MDS entry form.
Resident RAP Keys - for triggered categories, selected categories, or all
categories. Option to print the guidelines for the RAP Keys selected.
Quarterly Processing - including the Assessment Data Entry, Inquiry and
Quarterly Assessment Print. Screens show Annual, as well as, 1st through 3rd Quarter comparative
data.
Statistical Data - Display, List, and Count Residents by MDS Category,
Medications, RUGs Score, or RAP Category.
Display and List Missing Assessments, Incomplete Assessments, and Assessments
Due, both for MDS and Quarterly MDS.
Current Assessment List - summarizes all current assessments on file, admission
date, last annual assessment date, next annual assessment date, quarterly assessment dates, and
indicators to show those assessments due.
HCFA-672 (Resident Conditions) and HCFA-682 (Resident Roster) are produced
for any date, on demand, from the resident assessments using the category/condition cross reference,
and allows maintenance for data changes.
Controlled Access - Based on a given user id, only those sections applicable to
certain disciplines will appear for completion.
Inconsistency and Incomplete Audits - have been designed to permit the entries
necessary to seal the MDS assessment conveniently in the audit section without having to go back in to
the various assessment sections.
The MDS Database, including the RAP categories, Triggers, and Guidelines, is
user-maintainable. The initial Master Files for the MDS and applicable MDS+ standard formats are
provided; additional sections can be added and/or changed as needed. The resident's RUGs Score, RAPs
and Triggers, Quality Indicators, and HCFA-672 and 802 reports are automatically calculated.
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