Page 12 - Homecare Homebase: Skilled Nursing Training Manual

5. Enter the MD’s last name, and select the magnifying glass.
6. If you find the correct MD, tap on their name, and their info will populate into the Primary or Secondary box.
7. If you are replacing an existing Primary MD or moving them to the Secondary position, note that information in
the existing detail will disappear
8. Tap Save.
9. Back out to the Visit console and continue the visit.
If you cannot find the physician in the database OR you are outside of a visit:
1. You must create a “Demographic Change Request” coordination note.
2. Include as much MD information as you can. Minimum information should be MD first and last name, address
and phone #
3. Sync your Device
4. The request will then go to the branch IC to input the physician into the database

Vital Signs and Measures

o Complete all vital signs and check the parameters here.
o Fill in PAIN
 If you choose to enter pain under vital signs, you are required to answer PAIN on the physical
assessment. You do not have to enter it under vital signs but you must address it in the physical
assessment

o If unable to collect 1 or more vital signs, click “unable to collect” at the bottom of screen. Then enter a
reason.

• Interventions Goals
• The intervention/ goals section will contain DEFAULT interventions and goals that may or may not be applicable
for the patient. The intervention/ goals section for subsequent visits will be determined by the Pathways that
the clinician created “customized” for the patient in Start of Care. The objective in this section is to ensure the
default interventions/goals DO NOT carry over to the subsequent visits.
• Click on each item, then select either Provided, or Not Provided
o NOTE: For the visit to be billable, the clinician must provide at least ONE intervention).
o Click on Add Required Details to either manually enter the specific intervention details provided to the
patient DURING that visit, or choose prepared details.
• Next, enter the goal for the intervention as either Met, or Not Met.

o If choosing Not Met, the clinician will be required to enter a reason. Choosing a RED reason will prevent
this intervention from carrying over to subsequent visits. Choosing the goal as MET will also prevent it
from carrying over as well.
o In this section, you indicate which interventions you PROVIDED during this visit. If there is an
intervention you want permanently removed from the list for this patient, mark NOT PROVIDED and
choose a RED text option as a reason. “Red is Dead”, this intervention will not appear on further
subsequent visits.

Client Meds

Visit Actions → New Order, on subsequent visits
o Indicate Order Date & Verbal Order Date and Time. Write in “Instructions” box a descriptor, such as “New
Medication order”. Then click on “Add Medications”
Visit Actions →Client Meds, if on admission

o Click “Add” to enter a new medication
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10/1/2018