The clinical module is used to document direct point of patient care activities, physician’s orders, and includes a customizable plan of care. Comprehensive assessments addressing all CoPs with detailed nurse visits and focus notes, including integrated pain management, provide for increased compliance and improved quality of patient care.

Documenting quality measures has never been easier for staff. Hospice Item sets are embedded within their respective assessments enabling the clinical team to capture quality measures for all patients. The HIS, (Hospice Item Set Dashboard), enables providers to identify admission and discharge data elements for patients required for reporting, create compressed files in accordance with HIS specifications and submit information in a timely fashion.

Medical Assessments

• Medication Management
• Treatment Management
• Nutrition
• Metabolic
• Elimination
• Activity/Exercise
• Respiration/Circulation
• Sleep/Neuro/Musculoskeletal
• Cognitive/Perceptual
• Medical History
• Wound Care
• Teaching
• Comfort/Pain
• Fall Risk

Psychosocial Assessments

• Behavioral
• Support Roles and Relationships
• Patient/Family Coping
• Stress/Home Environment
• Sexuality
• Value Beliefs
• Assessment Comments
• Case Management
• Geriatric Depression Scale
• Mini Mental State Exam

Ancillary Assessments

• Face-To-Face Visit
• Physician Review of Systems Assessments
• Volunteer
• Spiritual
• Bereavement
• Risk
• Music
• Home Safety Checklist
• Oxygen Safety
• Referral
• Child

Hospice Item Set / HIS Dashboard

• NQF 1617 – Opioid / Bowel Regimen
• NQF 1634 – Pain Screening
• NQF 1637 – Pain Assessment
• NQF 1638 – Dyspnea Treatment
• NQF 1639 – Dyspnea Screening
• NQF 1641 – Treatment Preferences (POLST)
• NQF 1647 – Discussion of Religious Concerns

Orders

• Diagnosis and Treatment
• Request for Consultation
• Physician’s Orders
• Standing Orders
• Health Aide Request
• Patient Level of Care Change
• Discharge Summary
• Death Record

Plan Of Care

• Care Needs
• Goals and Interventions
• Medical Update
• Initial/Ongoing
• Bereaved

Progress Notes

• Doctor Note
• Health Aide Activities
• Nurse Note (Meds Screen)
• Nurse Daily Report
• Incident Report
• Focus Note
• Supervisory Visit
• Inpatient Notes
• Music Visit
• Spiritual Care
• Lab History
• Time Sheet Entry
• Patient Attachments

Communications

• Patient Alerts
• HIPAA-Compliant In-basket w/ internal e-mail
• HIPAA-Compliant Mail Box w/ internal e-mail
• Team Report

Data Input

• Smart Phones
• Laptops
• Remote Synchronization