Orders
What is required for an allowed hand signature
legible signature, credentials, date
What components are necessary to complete on DC
DC oasis, DC summary, NOMNC, WI DC notice form
How do you complete a DRR on SOC
Compare meds in home to signed med list from referral to the med list entered into PCC
When should you start your visit note
First thing upon entering the client’s home
Where do you document an on call note
Under the communication note select on call logging. Select the client and the Waupaca on call client.
what is required for an allowed electronic signature
name, credentials, date and time
How many days do you have to sign a DC oasis
2 days from DC date, but it should typically be able to be signed same day.
What do you do if the client has a medication in the home that is not on their med list?
Call PCP to clarify if client should be taking, add to med list if they approve, enter VO in notes to provider on the POC
When should you end your visit note
Last thing prior to leaving the clients home
Where do you document an on call note that is clinical in nature
Under the communication note select on call logging, select the patient and Waupaca on call client. Copy and paste into the patient centered care coordination note in PCC under the client
What do you do if you are starting your 1w3 and all your education interventions and goals have not been met?
Call PCP and get orders to increase frequency, discontinue frequency on care plan tab, enter new frequency, complete a SAA document on DC planning page in the visit note progressing behind schedule
What do you need to do prior to completing your DC oasis during a DC visit
Go into PCC and ensure the interventions and goals are completed
What do you do if a client has a med on their med list that they do not have in the home
Call PCP and notify them, see if they want the client to take, if they do, enter the med and enter VO on notes to provider section on POC. If they say no, educate client not to take and document
When should you complete documentation
In the client’s home prior to ending the appointment
1: Where do you document clinical conversations in between visits
2: What types on conversations are necessary to document in the PCCC note
1: In the patient centered care coordination note in the client’s chart
2: Conversations with provider office, conversations with client, conversations with client
what do you do if you receive an order without an allowed signature
call to get a verbal, enter the intervention/med sign and send the order
1: What is your M090 date assessment completed date for a transfer oasis
2: What is the M0906 date of transfer for a transfer oasis
1: The date we were notified of the transfer
2: The date the client was transferred to the inpatient facility
What do you do if a client has Tylenol 325mg take two tabs on their med list but they have 500mg tabs in the home
Call PCP to request order change to 500 or 1000mg. Update med list and enter VO in notes to provider section on POC
When should you sign a visit note
While in the home prior to ending the appointment
How many days do you have to sign a recert assessment:
By day 60 of the current cert period
what do you do if you receive an order with an allowed signature
Enter intervention/med, sign the order that is created and enter the comment paper order, click bypass sending to provider, select transcriber order and enter the signed date
1: How many days do you have to sign a SOC assessment
2: How many days do you have to sign a ROC
1: 5 days from SOC
2: 2 days from referral date
Your client reports they started taking a new over the counter medication, what do you do
Contact PCP, get VO, add to med list, select yes new med and complete the DRR, enter an intervention on the care plan page to educate on new medication and then document the education provided that speaks to dose frequency and side effects.
What do you do if you forgot to document something in your visit note and it is signed
Go into PCC and add a clinical note, type addendum to SVN dated… and then enter the documentation that was missed.
What steps should you take if you have 2w2 1w3 left in your frequency but all of the education interventions and goals are met
Call the provider and get an order to decrease, discontinue the frequency in the care plan tab, enter an updated frequency of 1w3 sign and send the order, document on the DC planning page in the visit note progressing ahead of schedule frequency decreased, complete an HHCCN and SAA