Ecw V10 Care Plan 6c1c5a

Care Plan November 2014

© eClinicalWorks, 2014. All rights reserved

CONTENTS ABOUT THIS GUIDE __________________________________________________4 Product Documentation ___________________________________________________________4 Webinars ___________________________________________________________________________ 4 eClinicalWorks Newsletter _____________________________________________________________ 4

Getting __________________________________________________________________5 Conventions_____________________________________________________________________5

CARE PLAN ________________________________________________________6 Care Plan Setup__________________________________________________________________6 Setting Security Access For Care Plan ____________________________________________________ 6 Create Care Plan Visit Type ____________________________________________________________ 7 Create Care Plan Compendium _________________________________________________________ 8 Creating a List of Problems, Goals, and Objectives_______________________________________ 8 Mapping ICD Codes to Problem List _________________________________________________ 11 Adding Frequencies, Modalities, Care Plan Status, and Rules _____________________________ 12 Add Frequency _______________________________________________________________ 13 Add Modality ________________________________________________________________ 14 Add Status___________________________________________________________________ 14 Specify Care Plan Rules_________________________________________________________ 16 Marking Problems, Goals, Objectives, Frequency, Modalities, and Status as Inactive __________ 17 Displaying the Active and Inactive Statuses _________________________________________ 17 Editing Problems, Goals, Objectives, Frequency, Modalities, and Status _____________________ 18 Editing Problems, Goals, and Objectives ___________________________________________ 18 Editing Frequency, Modality, and Status ___________________________________________ 19

Patient Care Plan________________________________________________________________20 Care Plan Case _____________________________________________________________________ 20 Creating Care Plan Case From Progress Notes _________________________________________ 20 Creating Care Plan Case From Referrals ______________________________________________ 22 Problems, Goals, and Objectives in a Care Plan ___________________________________________ 23 Adding Problems, Goals, and Objectives to a Care Plan__________________________________ 23 Asg Staff Member to Care Plan Problem ______________________________________ 26 Adding Problems That are Not Part of the Compendium_________________________________ 27 Deleting or Updating Problem, Goal, and Objective in a Care Plan _________________________ 28 Adding Notes for Care Plan Problems ________________________________________________ 29 Interventions for Care Plan Problems ________________________________________________ 31 Adding Intervention for an Objective______________________________________________ 31 Adding Addendum to an Intervention _____________________________________________ 33 ©Copyright

eClinicalWorks, November 2014 - Care Plan Guide

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CONTENTS

View Care Plan Case _________________________________________________________________ 34 Care Plan Hub ______________________________________________________________________ 35 Care Dates Tab __________________________________________________________________ 35 Care Team Tab __________________________________________________________________ 36 Care Plan Tab ___________________________________________________________________ 37 Printing Care Plan Summary by Problem Status _____________________________________ 39 Viewing the Intervention Status__________________________________________________ 40 Care Plan Encounters Tab__________________________________________________________ 41 Care Plan Notes Tab ______________________________________________________________ 43 Care Logs Tab ___________________________________________________________________ 43 Care Plan Discharge Summary Tab___________________________________________________ 44 Care Plan Setup Tab ______________________________________________________________ 47 Multiple Signatures on Care Plan Hub________________________________________________ 48 Reviewing a Signed Care Plan Document___________________________________________ 50 Print Options____________________________________________________________________ 51 Import Care Plan Cases ______________________________________________________________ 51 Close Care Plan Progress Notes and Cases _______________________________________________ 53 Printing, Faxing, and Locking Care Plan Progress Notes __________________________________ 53 Closing Care Plan Case ____________________________________________________________ 54

Care Plan Manager ______________________________________________________________56 Viewing Open and Closed Cases _______________________________________________________ 56 Message Board _____________________________________________________________________ 57

APPENDIX A: NOTICES ______________________________________________ 60 Trademarks ____________________________________________________________________60 Copyright ______________________________________________________________________60

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ABOUT THIS GUIDE This document provides information about the Care Plan module that can be used within eClinicalWorks® application to treat patients on a treatment plan over a period of time.

Product Documentation The eClinicalWorks documentation s the eClinicalWorks Electronic Medical Record (EMR), Practice Management (PM), and/or additional software features. eClinicalWorks Documentation is available from: 



https://my.eclinicalworks.com 

click the Documents and Videos widget on the Knowledge tab to display the documents available in PDF format



click the HelpHub widget on the Helpdesk tab to display the documents available in HelpHub

eClinicalWorks application - from the Help menu, click the HelpHub link

Webinars For more information, take advantage of the free unlimited eClinicalWorks webinars—interactive seminars conducted online. These courses are presented by product trainers who are experts with eClinicalWorks and all of its capabilities. To sign up for an eClinicalWorks webinar, go to: https://my.eclinicalworks.com. To view and for the webinars, from the Services tab click the eCW Webinar option.

eClinicalWorks Newsletter To receive important, timely, and informative product notifications, subscribe to the eClinicalWorks Newsletter e-mailing list. To subscribe to the newsletter: 

click the link available on the Customer Portal: https://my.eclinicalworks.com OR



click the link available on the eClinicalWorks website: http://eclinicalworks.com/ OR

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click the direct link: eClinicalWorks newsletter

© Copyright eClinicalWorks, November 2014 - Care Plan Guide

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ABOUT THIS GUIDE

GETTING

Getting Send messages directly to eClinicalWorks through the eClinicalWorks Customer Portal: https://idoc-pub.sitiosdesbloqueados.org/cdn-cgi/l/email-protection" class="__cf_email__" data-cfemail="ed9e989d9d829f99ad888e818483848e8c819a829f869ec38e8280">[email protected]

Conventions This section list typographical conventions and describes the icons used to call out additional information and to indicate item keys, new features, and enhancements to the application. 

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Typographical conventions: Bold

Identifies options, keywords, and items in a description.

Italic

Indicates variables, new and concepts, foreign words, or emphasis.

Monospace

Identifies examples of specific data values, and messages from the system, or information that you should actually type.

Icons are used to highlight new features and indicate enhanced features and item keys:

Icon

Description Indicates an item key. Identifies new features, suggested by clients, from the eCWIdeas website: http://ecwideas.eclinicalworks.com. Identifies new features. Indicates an enhanced feature. Points out helpful tips or additional information. Indicates feature meets a Meaningful Use requirement.

Note to Cloud/SaaS s: When accessing the eClinicalWorks application via RDP (Remote Desktop Protocol) as a backup, be advised that Microsoft® Office® applications such as Excel® and Word® will not be ed.


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CARE PLAN The Care Plan module is used by the providers to treat patients on a Care Plan where they will be seen over a period of time. The system enables the providers to manage such episodes and monitor their patient’s treatment plan over a period of time. The Care Plan module can be used in various treatment plans for shortterm and long-term care, such as weight-loss, anger management, etc. Note: This feature is an item key that is enabled by default. To disable this feature, eCW and refer to Item Key Code 0098_UK. For more information, refer to Getting .

For more information on Care Plan, refer to the following sections: 

Care Plan Setup

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Patient Care Plan

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Care Plan Manager

Care Plan Setup The following sections describe the setup that must be created prior to working with patient Care Plan. For more information, refer to: 

Setting Security Access For Care Plan

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Create Care Plan Visit Type

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Create Care Plan Compendium

Setting Security Access For Care Plan Care Plan Progress Notes can be restricted to s with proper access. To give proper access to s for Care Plan Progress Notes: 1. From the File menu, click the Security Settings option. The Security Settings window opens: 2. Click the By Security Attribute tab. A list of security attributes display on the left pane. 3. Select Patient Care Plan Access from the left pane:

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A list of available s display on the right pane. 4. Check the boxes next to all the s who would need access to the patient’s Care Plan Progress Notes. 5. Click Save. The specified security permission is now saved for the . s with access to patient Care Plan can view Care Plan Progress Notes.

Create Care Plan Visit Type 

After the module has been activated, visit types for Care Plan must be created from the section.

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The Care Plan Visit box must be checked for such visit types:

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Create Care Plan Compendium An can create a compendium of items for treatment plans. The compendium can be used to form a library of various objectives and goals that can be used to solve patient’s problems. Other configurations, such as mapping ICD codes with problems and setting up frequencies, modalities, and Care Plan rules can also be done. For more information, refer to: 

Creating a List of Problems, Goals, and Objectives

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Mapping ICD Codes to Problem List

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Adding Frequencies, Modalities, Care Plan Status, and Rules

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Marking Problems, Goals, Objectives, Frequency, Modalities, and Status as Inactive

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Editing Problems, Goals, Objectives, Frequency, Modalities, and Status

Creating a List of Problems, Goals, and Objectives A library of problems, goals, and objectives could be set up prior to creating Care Plans for patients. These goals and objectives can then be mapped to the problems so that the can select a course of action for the Care Plan from an available list of mapped items. For example, to treat a patient-problem of diabetes, a goal of controlling diabetes can be set and an objective of eating healthy can be made to achieve the goal.

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Problems relate to behavioral or physical conditions that the patient is facing.

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Goals relate to an achievable target set to overcome the problem.

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Objectives relate to modes of achieving the goals.

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One problem can be linked to multiple goals and objectives.

To create a problem list: 1. From the EMR menu, point to Miscellaneous Configuration Options, and then click Configure Care Plan Compendium. The Care Plan Compendium window opens. There are three sections in the Create Problem List tab: Problems, Goals, and Objectives. 2. From the Create Problem List tab, click the plus (+) icon. The Create New Problem window opens:

3. Enter the name of the problem in the Problem field. 4. Click Save. The name is added to the list of Problems on the Care Plan Compendium window:

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To search a problem by its name, enter the name in the search field and the problem will display underneath. The search used here is a wildcard search.

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To delete a problem, select the radio button corresponding to the problem and then click the minus (-) icon.

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To add goals and objectives, follow the same set of steps for the corresponding sections as used in adding problems.

To map problems, goals, and objectives: 1. From the Create Problem List tab, select the radio buttons corresponding to the problem, goal, and objective that should be associated. 2. Click Add next to Problems->Goals->Objectives. The mapping for Problems->Goals->Objectives is displayed:

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To remove an association, click the Delete (x) button to the left of the Problem-Goal-Objectives mapping.

Mapping ICD Codes to Problem List ICD Codes can be linked to problems. When a diagnosis is specified in the Progress Notes, it triggers the associated problems, goals, and objectives in the Care Plan. One ICD Code can be mapped to multiple problems. To map ICD Code to Problem List: 1. Click the Associate ICDs with Problem List tab in the Care Plan Compendium window. 2. From the ICD Codes list, select the radio button corresponding to an ICD Code. 3. From the Problems list, check a box corresponding to a problem that should be mapped to the ICD Code. 4. Click Map. The ICD Codes to problem list mapping displays:

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To delete an association, click the Delete (X) button to the left of the ICD Code-problem mapping.

Adding Frequencies, Modalities, Care Plan Status, and Rules Certain elements that define a Care Plan can be configured from the Setup tab of the Care Plan Compendium window:

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The following elements are used to define a patient’s Care Plan: 

Under Frequency, the number of times the patient is required to visit the clinic can be specified, such as once a week.

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Under Modality, the method of treating a problem can be specified, such as Group Therapy or Collateral.

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Under Status, various status options for Care Plan problems can be added, such as In Progress and a score can be specified for each status option, such as 10, 20, etc. The status is used to track the progress of the patient’s case on a Care Plan chart.

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Under Care Plan Rules Setup, specific rules for care dates and Care Plan labels can be added.

Add Frequency To add a frequency: 1. Click the Setup tab from the Care Plan Compendium window. 2. Click the plus (+) icon next to Frequency. The Create New Frequency window opens:

3. Enter the frequency of visits required, such as weekly. 4. Enter the duration in days, such as once. 5. Click Save. The frequency is added. To delete a frequency, select the frequency and then click the Delete (-) button.

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Add Modality To add modality: 1. Click the plus (+) icon next to Modalities. The Create New Modality window opens:

2. Enter a method of treatment. 3. Click Save. The modality is added. To delete a modality, select the modality and then click the Delete (-) button.

Add Status To add status: 1. Click the Plus (+) icon next to Status. The Create New Status window opens:

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2. Enter a status name in the given field. 3. Enter the score that determines the status. The score can be used later to graph the progress of the Care Plan. 4. Click Save. The status is added and displays the score in parentheses:

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CARE PLAN SETUP To delete a status, select the status, and then click the Delete (-) button.

Specify Care Plan Rules To specify Care Plan rules: 1. In Care Plan Rules Setup’s first field, enter the maximum number of days by which a patient should sign off on a Care Plan. 2. Enter the maximum number of days by which a Care Plan should be reviewed in the second field. 3. Enter the maximum number of days for a Care Plan utilization in the third field. This signifies the maximum number of days by which a team of people should analyze the Care Plan to see if appropriate resources were utilized. The maximum number of days rules are reflected in the Care Manager window under due dates reminders and in the Care Dates tab of the Care Plan Hub. The due dates are calculated based on the date when the case is created and the maximum number of days allowed. 4. Enter the number of days in the Care Plan Preview Days Span field. The Care Plan preview days span is the period for which the messages, reminders, and events are displayed for preview in the Care Plan Manager window. 5. Select Yes or No radio button for Autogenerate Care Plan Label. If Yes is selected, the system automatically generates a case label when a Care Plan case is created. 6. Select Yes or No for Prefix Care Plan Label with Care Plan Type. If Yes is selected, the system automatically prefixes the case label to the case type when a Care Plan case is created. Note: The mandatory fields are marked with a red asterisk and must be completed before you click Submit. 7. Click Save:

The Care Plan rules are added.

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Marking Problems, Goals, Objectives, Frequency, Modalities, and Status as Inactive If providers no longer require Problems, Goals, Objectives, Frequency, Modalities, and Statuses used in previous encounters for any current or future encounters, mark the Problems, Goals, Objectives, Frequency, Modalities, and Statuses as Inactive. To mark Problems, Goals, Objectives, Frequency, Modalities, and Status as Inactive: 1. From the EMR menu, point to Miscellaneous Configuration Options, and then click Configure Care Plan Compendium. The Care Plan Compendium window displays. 2. Click the Care Problem List tab or the Setup tab as needed. 3. Click a Problem, Goal, Objective, Frequency, Modality, or Status, as needed. The Create/Update window displays. 4. Check the box Make Inactive, and then click Save:

The inactive item is hidden in the list.

Displaying the Active and Inactive Statuses Use the Show All check box on the Create Problem List and Setup tabs in the Care Plan Compendium window to display items in Active and Inactive status. To display the Active and Inactive statuses: 1. Check the Show All box to display Active and Inactive Problems, Goals, Objectives, Frequency, Modalities, and Status:

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The Inactive elements display in bold:

2. Clear the selection for the Show All box to display only the Active items.

Editing Problems, Goals, Objectives, Frequency, Modalities, and Status The items in the Problem, Goal, Objective, Frequency, Modality, and Status list are editable links. Click these links to open the Create/Update window and edit the properties of the item as needed.

Editing Problems, Goals, and Objectives To edit Problems, Goals, and Objectives: 1. From the EMR menu, point to Miscellaneous Configuration Options, and then click Configure Care Plan Compendium. The Care Plan Compendium window displays. 2. Click the Create Problem List tab. 3. Click a Problem, Goal, or Objective from the list as needed:

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The Create/Update window for that item displays. 4. Change the name of the Problem, Goal, or Objective as needed. Check the Make Inactive box as needed:

5. Click Save. The Problem, Goal, or Objective is saved.

Editing Frequency, Modality, and Status To edit Frequency, Modality, and Status: 1. From the EMR menu, point to Miscellaneous Configuration Options, and then click Configure Care Plan Compendium. The Care Plan Compendium window displays. 2. Click the Setup tab. 3. Click a Frequency, Modality, and Status from the list as needed. The Create/Update window for that item displays. 4. Change the Frequency, Duration in Days, Modality, Status, and Score as needed. Check the Make Inactive check box as needed. 5. Click Save. ©Copyright


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PATIENT CARE PLAN The Frequency, Modality, and Status is changed.

Patient Care Plan The following sections describe how to create, modify, view, close, and import care plan cases for a patient: 

Care Plan Case

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Problems, Goals, and Objectives in a Care Plan

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View Care Plan Case

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Care Plan Hub

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Import Care Plan Cases

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Close Care Plan Progress Notes and Cases

Care Plan Case Patients can be seen on a case-by-case basis; therefore the must create a Care Plan case to document a Care Plan for a patient. For more information, refer to: 

Creating Care Plan Case From Progress Notes

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Creating Care Plan Case From Referrals

Creating Care Plan Case From Progress Notes A Care Plan Case can be created from the Progress Notes of a Care Plan Visit. Note: A patient can have multiple Care Plans open at the same time. For example, a patient can have two active Care Plans at the same point of time, such as Depression Care Plan and Weight Loss Care Plan. To create a new Care Plan case: 1. Create an appointment with a Care Plan visit type. 2. From the Progress Notes of the visit, click Problems:

The Care Plan window opens. 3. From the Care Plan window, click New Care Plan: ©Copyright


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The patient’s Care Plan Hub window opens. A label is generated automatically for the case in the Case Label field and can be changed manually:

4. Click the More (...) button next to the Care Plan Type field. The Case Types window opens:

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5. Select a case type code and click OK. To add, update, or delete case types, use the New, Update, and Delete buttons respectively. 6. Click the Create button located next to the Case Label field. The case is created and the due dates are displayed:

7. Close the window. Note: The auto-generated case label has a prefix of the selected case type, followed by the year, month, date, and time of the case creation. Automatically generating case label and prefixing case type to the case label is a -defined setting that is configured in the Care Plan rules setup.

Creating Care Plan Case From Referrals Care Plan cases can also be created from the Referrals window. To create a Care Plan from Referrals: 1. Open the Referrals window.

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2. Click the N button to open a drop-down list, and then click Case Plan Manager:

The Care Plan Hub window opens. 3. Create a new case from the Care Plan Hub window. For more information on creating a new case, refer to Care Plan Case.

Problems, Goals, and Objectives in a Care Plan A Care Plan consists of problems and related goals and objectives for a patient that can be added or modified over a period of treatment. For more information, refer to: 

Adding Problems, Goals, and Objectives to a Care Plan

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Adding Problems That are Not Part of the Compendium

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Deleting or Updating Problem, Goal, and Objective in a Care Plan

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Adding Notes for Care Plan Problems

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Interventions for Care Plan Problems

Adding Problems, Goals, and Objectives to a Care Plan Problems and their related objectives and goals can be added to a patient’s Progress Notes and Care Plan. A patient’s case can have multiple problems, goals, and objectives, and providers can work on them simultaneously. To add problems, goals, and objectives to a patient’s Care Plan visit: 1. From the Progress Notes of the Care Plan visit, add an ICD Code (from the Assessment window) for the problem. 2. Click Problems:

The Care Plan window opens. The ICD Code that was added in the Progress Notes displays along with its description: ©Copyright


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3. Click an ICD Code to open the list of problems, goals, and objectives that were mapped to the selected ICD Code:

Note: One ICD Code can be mapped to multiple problems and one problem can be linked to multiple goals and objectives. As a result, an ICD code can trigger a list of same problems that are linked to different goals and objectives. The can select one or many combination of problems-goalsobjectives from this list as needed for the visit. 4. Click the arrow next to a row to add a problem and the related goal and objective. Repeat this process to add multiple combinations of problems, goals, and objectives. 5. Click Close.

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The problem, goal, and objective is added to the Care Plan window.

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To enter notes for a specific problem, goal, and objective, select a row from the Care Plan window and type your notes in the Notes field.

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To browse notes from a predefined list, click Browse and select a note.

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To check spelling for the notes, click Spell Check.


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To delete the notes that was entered, click Clear.

6. Double-click a problem row in the Care Plan window. The Care Plan Problem window opens:

7. From the drop-down lists corresponding to the fields, select a frequency and modality for the problem. The drop-down lists display options that were configured during Care Plan setup. 8. Click the Prv or Staff button to select a provider or staff member who is treating the problem-goal-objective. For example, if the modality is individual treatment, and frequency of visit is once every week, the provider who would supervise the problem-goal-objective could be a physical therapist. Note: Different providers could be working together on the same patient on the same care plan. For example, one provider could be focused on a single objective and devising a treatment plan, while another provider could be treating the other objective(s) for the same patient's care plan. There can be multiple providers treating the patient on a single care plan. 9. From the drop-down calender in the Completion Dt. field, select a date to specify the expected date by which the problem should be resolved. 10. Drag the pointer under Status to specify the current status of the problem.

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The Status displays a score that was configured during the Care Plan setup.

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The status of the problem, goal, and objective can be updated periodically as the treatment progresses.


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The Care Plan chart is plotted for each set of patient’s problems, goals, and objectives based on their status score.

11. Click Save to save the information for the problem. 

Click Save & Next to save the current information and to move to the next problem.

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Click Cancel to exit without saving.

12. Click Close. The problem, goal, objective, and notes are added to the Care Plan section of the Progress Notes.

Asg Staff Member to Care Plan Problem In earlier versions, a Problem-Goal-Objective could be assigned to a provider. Now, a Problem-Goal-Objective can be assigned to a staff member. To assign Problem-Goal-Objective to a staff member: 1. Open the Care Plan Problem window. 2. Click Staff:

The Staff Lookup window displays. 3. Select a staff member, and then click OK. 4. Click Save. The Problem-Goal-Objective is assigned to the staff member.

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Adding Problems That are Not Part of the Compendium Problems, goals, and objectives could be unique to a patient and may not be found in the compendium. In such cases, the provider can add them at the encounter level without adding them to the compendium. To add problems, goals, and objectives at the encounter level: 1. From the Care Plan window, click Add Problems:

The Care Plan Encounter Data window opens:

2. Add a problem, goal, and objective by clicking the Plus (+) icon in the corresponding sections. For more information on adding problems, goals, and objectives to the compendium, refer to Create Care Plan Compendium. 3. Click Add next to Problems->Goals->Objectives.

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4. Click Close. The problem and the associated goal and objective is added to the Care Plan window:

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Deleting or Updating Problem, Goal, and Objective in a Care Plan If a provider does not want to work on all the problems, goals, and objectives during a patient’s current visit, they can remove those problems, goals, and objectives from the current visit’s Care Plan window. On the other hand, as the treatment progresses, the provider can update the status of the problem-goal-objective. To delete or update a problem, goal, and objective in a Care Plan: 1. From the Care Plan window, select a problem. 2. Click the green arrow next to Add Problems to open a drop-down list:

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3. Select Delete or Update, as needed. 

When Update Problems is clicked, the Care Plan Problem window opens. Edits can be made to this window.

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When Delete Problems is clicked, the problem, goal, and objective is removed from the Care Plan window.

Adding Notes for Care Plan Problems The system carries information entered in the Notes box in the Care Plan window to the Notes tab of the Patient’s Care Plan Problem window. The Notes tab of the Patient’s Care Plan window adds a structured data functionality. To use the Notes tab in the Patient’s Care Plan Problem window: 1. Click Problems in the Patient’s Care Plan Progress Notes. The Care Plan window displays. 2. Select the patient’s existing Care Plan from the Select Care Plan drop-down list. To add a new Care Plan, click New Care Plan. 3. Click Add Problem and add one or more Problem, Goal, and Objective combination. The Problems, Goals, and Objectives display. 4. Click a row of Problem, Goal, and Objective to select it, and then enter any additional notes in the Notes box below:

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5. Click the green arrow next to the Add Problems button, and then click Update Problems. The Care Plan Problem window displays. 6. Click the Notes tab. Any notes added in the previous Care Plan window displays under the Notes tab:

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To create a list of pre-defined notes, use the New button.

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To create and use structured data questions for pre-defined notes, refer to the Progress Notes Customization section of the Electronic Medical Records s Guide.

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To add notes in the Notes box, simply type the notes and use the Browse, Spell Check, and Clear functionality as necessary.

7. Click Save.

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PATIENT CARE PLAN The Notes information, including the structured data responses, display in the Progress Notes.

Interventions for Care Plan Problems From the Interventions tab of the patient’s Care Plan Problem window, providers create Interventions to complete objectives. Interventions is an optional feature and can be used as required. The following hierarchy describes the approach towards reducing patient's problems: Identify patient’s problems.

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Set goals to reduce patient’s problems. •

Establish objectives to achieve goals. 

Create interventions to complete objectives.

The following describes an intervention created to complete an objective:

Problems John is unable to find a job

Goals John would like to be employed in a part-time job

Objectives

Interventions

Identify the kind of jobs John is good at and the kind of things he enjoys doing.

Help John in creating a portfolio of his personal achievements and strengths. (The intervention would help build John’s confidence in securing a job. It would assist him in ing his strengths. It would provide a task that requires focus, reduces distraction, and prepares him to finish work.)

Adding Intervention for an Objective To add an Intervention for an Objective: 1. In the Care Plan window, click a row of Problem, Goal, and Objective to select it. 2. Click the green arrow next to the Add Problems button, and then click Update Problems. The Care Plan Problem window displays. 3. Click the Interventions tab, and then click New Intervention. 4. Enter Intervention information in the text box:

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(Optional) Use the Browse button to select from a list of -defined keywords:

5. Click Save in the Care Plan Problem window. 6. Select one of the following options from the Status drop-down list:

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Active - Select this option if the intervention is currently in progress.

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Discontinued - Select this option when stopping the intervention.

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Achieved - Select this option if the intervention is complete:


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[

When a status changes, the name and the status change text display:

Note: The Intervention status displays in the Care Plan Hub, under the Care Plan tab. After adding an Intervention, the may or may not delete it. Use the Addendum button to document any additional information to the Intervention. Interventions display in the Progress Notes:

Adding Addendum to an Intervention To add an addendum to an Intervention: 1. Click New Addendum. 2. Add the Addendum: 

Enter the information in the text box and click Save. OR

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Use the Browse functionality to select from -defined keywords:


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3. Click Save. The Intervention is added.

View Care Plan Case Once a case has been built and problems, goals, and objectives have been added to the patient’s Care Plan visit, the can now view the Care Plan. This leads to problems, goals, and objectives that were added to today’s visit, to get linked to the case that is being viewed. To view a Care Plan case: 1. From the Care Plan window, select a Care Plan from the Select Care Plan field using the drop-down list. 2. Click View:

The Care Plan Hub for the selected case opens. 

The problems, goals, and objectives that were added to the current encounter display under the Care Plan tab. To add other problems, goals, and objectives to the case, click Add Problems in the Care Plan window.

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The current encounter is listed under the Encounter tab. Multiple encounters can be linked to a case. To learn how to link encounters, refer to Care Plan Encounters Tab.

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Care Plan Hub The Care Plan Hub provides a convenient, single point of access to all information available in a patient’s Care Plan case. For more information, refer to the following sections: 

Care Dates Tab

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Care Team Tab

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Care Plan Tab

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Care Plan Encounters Tab

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Care Plan Notes Tab

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Care Logs Tab

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Care Plan Discharge Summary Tab

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Care Plan Setup Tab

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Multiple Signatures on Care Plan Hub

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Print Options

Care Dates Tab Under the Care Dates tab, the Care Plan Review Due Date, Patient Sign-Off Due Date and the Utilization Due Date are displayed. These dates are auto-generated by the system based upon the case-creation date and the maximum number of days for each category. The maximum number of days for each category is configured in the Care Plan Setup. 

Review Due Date - This signifies the due date by which the care team should review the case and signoff on it.

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Patient Sign-Off Due Date - This signifies the due date by which the patient would agree to accept and sign-off on their Care Plan.

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Utilization Due Date - This signifies the due date by which a team of people should analyze the Care Plan to see if the proper treatment was provided and appropriate resources were utilized. This is usually performed by the insurance company after the case is closed. Note: These dates also display under Care Plan Manager as a reminder of the tasks that are due on individual cases. For more information on Care Plan Manager, refer to Care Plan Manager.

To log actions and view them: 1. Select the radio buttons corresponding to Case Review, Patient Sign-Off, and Case Utilization, as needed. 2. Add comments related to the action in the Comments field. 3. Click Sign In. The action is logged and is displayed along with the name, date, and time:

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4. Click the blue arrow link next to a logged action to view the comments. For more information on g and reviewing signatures, refer to Multiple Signatures on Care Plan Hub on page 48.

Care Team Tab Under the Care Team tab, the provider can add who are associated with treating a patient. For example, a patient may be treated for depression by a provider who has set an objective of exercising for the patient. On the other hand, they could be treated for the same problem, but with a different objective by a different provider. Therefore a Care Team should comprise of all staff and providers who contribute to a patient’s entire Care Plan. To add to a care team: 1. Click Add Team . The Staff Lookup window opens. 2. Select a staff member and click OK. The staff member is added to the Care Team:

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

To add other staff to the team, repeat steps 1 and 2.

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To delete a staff member from the team, select the radio button corresponding to their name and click the Delete (-) button.



To appoint a member as the lead clinician for treating the patient, select the radio button next to a provider. Note: The designated lead physician supervises the entire Care Plan. Lead Clinician for a Care Plan has been renamed as Lead Clinician/Case Manager.

Care Plan Tab The Care Plan tab displays all Problems, Goals, and Objectives for the patient:

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Click on the Plus (+) icon to view the notes, frequency, modality, and treatment provider, as well as a chart reflecting the current status for the problem-goal-objective:


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

The patient’s progress is plotted in blue against the optimal progress denoted in red.



The progress is plotted based on the status assigned to a patient’s problem-goal-objective over time and the score set for the status. For example, when a patient came in last week, their problem-goal-objective status was set at 10 for a care plan case. This week when the patient comes in, the provider can import the same care plan case from the Chart to the Progress Notes and update the status of the problem-goal-objective to 20, based on the progress. When the provider views the graph on the Care Plan Hub, it displays the progress of the status in the graph. For more information on importing care plan cases, refer to Import Care Plan Cases.



You can update a problem-goal-objective’s status each time you work on it, from the Care Plan Problem window. For more information on documenting a problem-goal-objective’s status, refer to Adding Problems, Goals, and Objectives to a Care Plan and Deleting or Updating Problem, Goal, and Objective in a Care Plan.

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Click Print Summary to open the Care Plan Discharge Summary window and to print the summary.

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Click the Printer icon to open the Print Care Plan window and select options to print. For more information on printing options, refer to Print Options.

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The visit type associated with the encounter displays next to the visit date. Click a visit date to open the patient’s Progress Notes for that date:


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Printing Care Plan Summary by Problem Status A drop-down field called Filter Problems has been added to the Care Plan tab in the Care Plan Hub. This field can be used to filter problems in the Care Plan tab based on the status of the problem, and to print Care Plan Summary by problem status. To print Care Plan Summary based on problem status: 1. Click the Care Plan tab in the Care Plan Hub. 2. Click the drop-down arrow in the Filter Problem field, and then select a status:

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PATIENT CARE PLAN Note: A status can be assigned to a Problem-Goal-Objective from the Care Plan window. The Problem-Goal-Objective display by status.

3. Click Print Summary to open the Care Plan Discharge Summary. The Care Plan Discharge Summary window opens displaying problems by the selected status:

4. Click Print.

Viewing the Intervention Status The status of an Intervention, documented in the patient's Care Plan Problem window, displays in the Care Plan tab of the Care Plan Hub. To view the status: In the Care Plan tab, click the Plus (+) icon to expand the Problem details. The status of the Intervention displays along with the date and the name of the that changed the status:

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For more information about changing the status of an Intervention, refer to Interventions for Care Plan Problems.

Care Plan Encounters Tab All encounters linked to the current Care Plan display under the Encounters tab. Additional encounters that are considered of significance to the patient’s Care Plan can be linked to the current Care Plan. That is, if a patient is being treated for any problems related to the current case but in a different visit, those encounters can be added to the Care Plan as a means to keep track of their treatment. To link encounters to the Care Plan: 1. Click Link Encounters. The patient’s Encounters window opens. 2. Select an encounter and click OK. The encounter is now linked to the case and displays under the Encounter tab:

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

The encounters are displayed under the Encounters tab by visit date, visit type, facility, and provider name.

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To remove an encounter, click the Delete (-) button corresponding to an encounter.

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To view an encounter, click the encounter date link. The patient’s Progress Notes for that encounter opens in a read-only format and displays the Care Plan information at the end of the Progress Notes:

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Care Plan Notes Tab Under the Notes tab, the provider can add general information that is outside the scope of the encounter. To add notes: 1. Enter your notes in the space provided. 2. Click Add Notes. The Notes are added. 3. Click the blue arrow link next to a logged note to view the notes:

Care Logs Tab Under the Care Logs tab, all activities on the Care Plan case that have been logged are displayed:

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Use the scroll button to move to the next page.

Care Plan Discharge Summary Tab From the Discharge Summary tab, the patient’s Care Plan Discharge Summary can be printed. The Discharge Summary is comprised of information on the patient and the care team, summary of problems, and Discharge Summary details. The Discharge Summary details can be customized by creating structured data questions. These structured data questions are available for all Care Plans. Responses to the structured data questions are specific to the Care Plan case, and are not carried over to other Care Plan cases. To create Discharge Summary questions and to print a Discharge Summary: 1. From the Discharge Summary tab, click Custom Discharge Structured Data. The Structured Data window opens. 2. Create a list of structured, numeric, Boolean, and date data-type questions, as needed. 3. Once the questions are created, click Close:

The structured data questions are displayed under the Discharge Summary tab. 4. Click a row to open the Care Plan Discharge Summary Data window. 5. Enter responses to the structured data questions:

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6. Click Close. The structured data questions and the responses associated to them are displayed under the Discharge Summary tab:

7. Click Print Discharge Summary. The Care Plan Discharge Summary window opens displaying the patient and care team information, summary of problems, goals, objectives, and the structured data entries:

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8. Click Print to print the Discharge Summary. Note: For more information on structured data, refer to the section titled Structured Data in the EMR s Guide. ©Copyright


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Care Plan Setup Tab Under the Setup tab, the can configure reminders for Care Plan Review, Care Plan Patient Sign-Off, and Care Plan Utilization. These reminders act as alerts for important due dates and display in red under the Care Dates tab of the Care Plan Hub and in Care Plan Manager > Message Board > Reminders. To configure reminders for Care Plan Review, Care Plan Patient Sign-Off, and Care Plan Utilization: 1. Click the Setup tab in the Care Plan Hub. 2. Select a trigger option from the Trigger drop-down list for Care Plan Review. 3. Enter the number of days in the field next to the Trigger option. For example, to set a reminder for every seven days, select Every in the Trigger field and enter the number 7 in the next field:

4. Repeat steps 1 through 3 for the Care Plan Sign-Off and Care Plan Utilization options. 5. Click Save. View the reminders in Care Plan Hub from the Care Dates tab:

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To view the reminders from the Referrals band, point to Care Plan Manager, Message Board, and then click Reminders:

Multiple Signatures on Care Plan Hub Use the Sign In button to capture multiple signatures on the Care Plan for the review process. For examples, if the Care Plan document was reviewed by multiple providers, social workers, and attorneys, s may capture their individual signatures manually or digitally using the Sign In button. To review and sign a Care Plan: 1. From the patient’s Care Plan Hub, click the Care Dates tab. 2. Select an appropriate radio button - Care Plan Review, Patient Sign-Off, or Care Plan Utilization Review. 3. Enter comments in the Comments field. 4. Click Sign In:

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The Care Plan Signature Capture window displays. 5. Click New Review to review the current Care Plan document. If reviewing the Care Plan document from the past, select the date from the drop-down list to display the Care Plan document from that date. 

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If using a Tablet PC, use the Stylus to sign in the Please Sign Below box, and then click Done:


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

If using a Signature Pad, click the Sign with Sig Pad button. For more information ing Signature Pads, refer to the Devices s Guide. •

To clear the signature, click Clear.

•

To print the signed Care Plan document, click Print.

6. Click Close to exit the window. eClinicalWorks® adds the Action, and indicates that the Care Plan document is signed and reviewed:

Reviewing a Signed Care Plan Document Use the Review Signature button to evaluate a signed Care Plan document. To review a signed Care Plan Document: Click the Review Signatures button and then select a date from the drop-down list. The signed Care Plan document displays. ©Copyright


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Print Options A Print icon is available for printing, next to the Print Summary button in the Care Plan tab and Print Discharge Summary buttons in the Discharge Summary tab. The Print icon enables s to choose specific options to display when printing the Discharge Summary. To select Print Options: 1. Click the Print icon to open the Print Care Plan window:

2. Check the options to display the related information in the Print Summary window: 

Care Plan Team



Care Plan Interventions



Care Plan Notes

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Care Plan Assessments

3. Click Print to open the Care Plan Discharge Summary window. 4. Click Print to print the Care Plan Discharge Summary.

Import Care Plan Cases Patient’s Care Plan cases and problems would be displayed in the Progress Notes under the Overview tab of the Chart . A patient can have several Care Plan cases or problems at one point. To address this situation, a provider can work on simultaneous problems during a visit by importing the problems-goals-objectives from a past encounter to the current one. To import all problem-goals-objectives within a problem from a Care Plan case to the current visit: 1. From the Chart of the current Progress Notes, click the Overview tab. 2. Click the arrow next to a problem, under a Care Plan case:

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The Care Plan window opens displaying the case name, goals, objectives, and the ICD Codes associated to the problem:

3. Double-click a problem row to open the Care Plan Problem window and to update the status of the problem-goal-objective. 4. Click Save to save the changes and return to the Care Plan window. 5. Select a row of problem-goal-objective, and enter notes in the Notes field. 6. Click Close. The problem and all the related problem-goal-objective and notes are imported to the Care Plan section of the current Progress Notes. Note: If a problem has multiple goals and objectives, they are imported to the Progress Notes as well. Note: Click the orange More (...) button next to the Care Plan name to open the Care Plan Hub. To import a specific combination of problem-goal-objective within a problem (rather than all problems-goalsobjectives within a problem) to the current visit: 1. Click the orange More (...) button next to a problem:

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PATIENT CARE PLAN The Care Plan Problem List window opens and displays any objectives, goals, frequency, modality, and provider associated to the problem:

2. Click the arrow next to a row to select that problem-goal-objective combination. 3. Close the window. The Care Plan window opens displaying the case name, goal, objective, and ICD Codes associated to the problem. 4. Double-click a problem row to open the Care Plan Problem window and to update the status of the problem-goal-objective. 5. Click Save to save the changes and to return to the Care Plan window. 6. Select a row of problem-goal-objective, and enter notes in the Notes field. 7. Click Close. The specific combination of problem-goal-objective and notes are imported to the Care Plan section of the current Progress Notes. Note: Since one problem can have multiple goals and objectives, the orange More (...) button that is described here is used to import a specific combination of problem, goal, and objective. Note: Once problems, goals, and objectives have been imported from a past encounter to the current one, the status of the problem-goal-objective can be seen in the Care Plan chart. For more information on the Care Plan chart, refer to Care Plan Tab.

Close Care Plan Progress Notes and Cases A Care Plan case can be closed and locked for use in future. For more information, refer to: 

Printing, Faxing, and Locking Care Plan Progress Notes



Closing Care Plan Case

Printing, Faxing, and Locking Care Plan Progress Notes Care Plan Progress Notes display Care Plan problems-goals-objectives and notes on top of the Progress Notes when locked, printed, or faxed. This feature is applicable to all styles of faxing, printing, and locking Progress Notes:

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Note: For more information on printing, faxing, and locking Progress Notes, refer to the Electronic Medical Records s Guide.

Closing Care Plan Case Once a Care Plan case is complete, it can be closed. A closed Care Plan case cannot be modified. However, the Discharge Summary can be printed anytime from a closed Care Plan case. To close a Care Plan case: 1. Open a Care Plan case. 2. Review the Care Plan and ensure that the Case Review, Patient Sign-Off, and Case Utilization is complete and logged under the Care Date tab of the Care Plan Hub. 3. Select the Closed radio button:

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A message displays confirming if you want to close the existing Care Plan. 4. Click OK to close the case. 5. Close the window. The case is locked for use and an alert message is displayed on the Care Plan Hub:

The following points are important to note when viewing closed Care Plan cases:

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If a tries to modify any item in the Care Plan Hub, a message will inform them that the case is closed.

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The can still print a Discharge Summary from the Discharge Summary tab of a closed case.

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All closed cases are displayed with an asterisk in the Care Plan Cases drop-down list.

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Closed cases can be viewed by filters, such as patient, lead clinician, case type, case label, and date range from the Care Plan Manager window.


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Care Plan Manager The Care Plan Manager is available under the Referrals band. s can keep track of open and addressed Care Plan cases through this section. They can also manage due dates that are significant to the patient’s Care Plan. The Care Plan Manager window is controlled by the security attribute Patient Care Plan Access. For more information, refer to: 

Viewing Open and Closed Cases



Message Board

Viewing Open and Closed Cases In the Care Plan Manager, s can see a list of open and closed cases by different filters. To view open or closed cases: 1. From the Referrals band, click the Care Plan Manager icon. The Care Plan Manager window opens. 2. Click the Open or Closed tab, as needed. 3. Apply the filters described below:

Filter Patient

Description Filter to search by patient name: 1. 2. 3.

Lead Clinician

Filter to search by lead provider in the care team: 1. 2. 3.

Click the More (...) button to open the Staff Lookup window. Click a provider/staff name to highlight it. Click OK. The selected provider/staff name displays in the chosen field.

Case Label

Filter to search by the case label. You can enter free text in this field.

Case Type Code

Filter to search by case type: 1. 2. 3.

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Click the More (...) button to open the Patient Lookup window. Click a patient to highlight it. Click OK. The selected patient displays in the chosen field.

Click the More (...) button to open the Case Types window. Click a case type. Click OK. The selected case type displays in the chosen field.


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Filter Date Drop-Down List

Description Filter to search by created date, review date, patient signoff date, and utilization date: 1. 2.

Date range fields

Click the arrow to open a drop-down list. Click a date type. The selected date type displays in the chosen field.

Enter the beginning and the ending dates of the date range by using the drop-down calendars.

To remove the selections made in the filters, click Clear. 4. Click GO to generate the query and display the results:

5. Click a row to open the Care Plan Hub for a case:

The Care Plan Hub displays.

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Message Board The Message Board contains reminders on important dates associated to a patient’s Care Plan case, a running list of messages or notes entered in the cases, and actions taken on a case. To view the Message Board: 1. From the Referrals band, click the Care Plan Manager icon. The Care Plan Manager window opens. 2. Click the Message Board tab. The Message Board opens, displaying reminders, messages, and events. The Reminders, Messages, and Events icons display an item count in brackets for each category:

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To view reminders only, click the Reminder icon. •

The Reminders page displays significant due dates, such as, review date due by.

•

The Reminders page displays the Care Plan case name and the patient’s name associated with it.

•

To open a case and take action on it, click the blue hyperlink for the Care Plan case or the patient name:


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



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To view messages only, click the Messages icon. •

The Messages page displays notes that were entered under the Notes tab in the Care Plan Hub and the that created the notes.

•

The Messages page displays the Care Plan case name and the patient’s name associated with it.

•

To open a case and enter notes in it, click the blue hyperlink for the Care Plan case or the patient name:

To view Events only, click the Events icon. •

The Events page displays any actions that were taken on a case along with the date and name.

•

To open a case, click the blue hyperlink for the Care Plan case or the patient name:

To refresh the Message Board, click the Refresh Cache icon.


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APPENDIX: NOTICES Trademarks eClinicalWorks® eClinicalWorks is a ed trademark of eClinicalWorks, LLC. All other trademarks or service marks contained herein are the property of their respective owners. Microsoft® Microsoft, Excel, and Word are either ed trademarks or trademarks of Microsoft Corporation in the United States and/or other countries.

Copyright Microsoft Copyright Notice ©2014

Microsoft Corporation. All rights reserved.


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