Admission Procedures
Resident Face Sheet
Information in the resident face sheet is shared throughout the Clinical
System, reducing the need to re-enter the same information into other programs.
For example, the resident's birth and admit dates are copied from the
face sheet into the resident's MDS record and care plan. If the Clinical
and Resident Accounting Systems are integrated, face sheet data can be
accessed through both systems.
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Record personal and demographic data required for
billing
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Include Medicare, Medicaid and other insurance
numbers
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Enter ICD9 medical diagnoses, Primary Physician
identification, and Family, Financial and Legal contacts
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Track advanced directives, religion, language,
discharge plan and other details
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Resident's financial data is automatically updated
with last billing, payment dates and balances by payer
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Record up to 99 separate notes per resident. Include
additional information such as medical history, maiden name, names
of spouse, parents, children and grandchildren; nationality or
ethnic background, etc
Physician Orders
The Physician Orders programs maintain the orders that will be printed on Order
Listings and Medication sheets (MARs) and Treatment Record Sheets (TARs) for residents' charts.
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Maintain Routine, Diet, Medication, Treatment, Lab
and Standing Orders or other facility-defined categories.
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Print
different order categories on different sheets for use by multiple staff
members (i.e. licensed vs. non-licensed)
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Print Order Listings which include all order types,
resident's room and bed number, diagnoses and allergies, physician
name and phone number, and the physician signature area
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Medication orders are coded with NDC codes and drug class
codes for Quality Assurance reporting
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Authorized users can edit the medication (NDC) library provided
with the system
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Electronic medication administration is also available. See
eMAR
Flow Sheets and Resident
Kardex
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Build and select from a library of procedures to
create individual resident's printed
flow sheets.
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Chart Activities of Daily Living (ADLs)
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Include Care Plan approaches that are coded to be
performed by a CNA
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Pull Kardex details from the Face Sheet, MDS
and Physician’s Orders
Calendar
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Schedule and track events that occur regularly, such
as dentist appointments or lab work
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Build a library of events that can be scheduled in
daily, monthly or annual increments
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Print or view the calendar sorted by resident or date
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Select date ranges, categories or individual
events
Documentation
Clinical Assessments
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Hi-Tech provides assessments for falls,
dehydration, bowel and bladder, etc., and you can build your own
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Create assessment questions with multiple choice answers, and
add a scoring system to the answers
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Print or display the assessments and include responses
for up to 5 assessment dates
Height and Weight
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Enter height and weight of each resident for
unlimited dates
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Print or display reports for specific residents and/or date
ranges, or for statistics
Activities
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Build a library of activities offered at your
facility
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Select a resident and record the activities attended
by that resident.
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When several residents attend the same activity,
record the activity and select the residents that attended
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Print or display reports for selected residents,
dates and/or activities
Inoculations
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Build a library of residents' inoculations
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Select a resident and record the inoculations
received by that resident
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When the same inoculation is given to all or most
residents, record the inoculation and select the residents
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Print or display reports for selected residents,
dates and/or inoculation types
Notes
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Enter regular notes and secure notes that can not be changed after
saving
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Date, time and user ID attach to each note
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Print or display by resident, note type or user
RAI and MDS processing provides
everything you need to submit error-free assessments that comply with
CMS regulations.
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Assessment Schedule and Alert List track
the assessments that must be completed and submitted
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Allows users to edit or only to view assessments,
based on user log-in
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Resident demographic information flows directly from
the resident's face sheet into the Admission assessment
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When you start a new assessment, begin with a copy of the last assessment and make
the required changes, or begin with a blank assessment and complete
all sections
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If your State requires medications with NDC
codes on Section U (Medications), copy meds from the med order file to Section
U where you can add, edit or delete meds and
access the NDC library
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System automatically checks each MDS for errors,
and will not print or submit an MDS until it is error-free
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MDS Data
Conflict Checking (pdf)
assures MDS accuracy by finding logical conflicts within an assessment
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The RAP Summary program calculates the triggered RAPs
and allows you to respond to each and provide additional
documentation in RAP Notes
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The
HTS Therapy Time System
exports therapy
minutes to Section P1b-Therapies
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As a Resource Systems Platinum Partner, HTS provides an excellent interface
to
CareTracker
that exports
resident demographic changes and imports MDS responses
MDS Submission
- Select all completed, error-free assessments through
the
“completed” date that you choose
- The
entire MDS history file is scanned each time to ensure that no
assessments are missed
Care Plans /
Service Plans
- Create
care plans from a library of Problems, Goals and Approaches provided
by the system
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Authorize staff to add, change or delete items in
the library
- Let
the system suggest problems based on triggered RAPS, or select problems
yourself from the library or create your own
- Assign
individual disciplines to carry out the approaches. Approaches
assigned to a CNA can be included on the resident's Flow
Sheet
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Reorganize the print sequence of problems to stress priorities
- Update
the entire care plan or specific Goal target dates
PPS Case Mix
- Print
or display case mix reports for one payer or all payers
- Include or exclude admissions
or discharged residents based on a census
date
- Use
the Case-Mix Calculator ("What If" programs) to view how
possible changes in resident conditions, new admissions or discharges
will affect your current individual RUG scores and facility Case Mix. These calculations do not affect any
actual records and can be edited or deleted as needed.
QIs / QAs / Survey Reports
Use your own data to help assess your quality of care
Quality Indicators Report
- Select
individual residents or QI categories
- Print
or display the report, sorted by resident or QI
- Print
or display a 12-month trend report
Quality Assurance Reports
- MDS –
compare or contrast responses for up to 9 different MDS questions; for
example, list all residents who have fallen in the last 30 days
(J4A) and are taking antipsychotic medications (O4)
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Medications – list residents taking a particular
med or meds from a particular class
- Care
Plans – list residents whose care plans include a specific problem, goal and/or approach
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Weights – list each resident, weight gained or lost in pounds
and percentages, and actual weight as a percentage of ideal weight
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Diagnosis - list residents whose face sheets include a
specific ICD9 diagnosis code
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Unresolved Conditions - Compare answers to critical questions
on the recent MDS to the previous MDS to see if these conditions are resolved; for example, UTIs,
vomiting, pneumonia, weight loss, etc.
Survey Reports
- Print
CMS 672 (Census) and CMS 802 (Roster) at anytime in anticipation of
surveyor audits
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Details are extracted from residents' current MDS records, and you
can update survey data through "worksheets" if MDS records do not
provide the most current information
Reporting
A variety of reporting options include
the ability to select details to design custom reports, For example:
·
Medicare Length of Stay
·
Medication List
·
Change Register for Physician’s Orders
·
Change Register for MDS
·
MDS Error List
·
MDS Alert Report
·
MDS Scheduling Report
·
Care Plan Goal Review
·
Custom Reports from Face Sheet details
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below to review our other long term care applications.
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