CLINICAL CARE • Assessment Forms (Clinical and · PDF fileNote: in this instance an image...

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CLINICAL CARE • Assessment Forms (Clinical and Administrative) • Care Plans (individualised per client and per staff role) • Progress Notes • Watch List for Shift Change Over Remote data entry for assessments is conducted via the optional add on i.on my Clinical App. This allows you to use your hand held devices and commence assessments at the point of care (as well as the desktop if wanted). Clinical App is highly flexible and designed to map to your needs. You decide and name the Domains and Assessments, you decide the forms/assessments, you even decide what images you want to use and how many are displayed across a page, e.g. 2,3, 4,5,6, etc. HIGHLY FLEXIBLE, DESIGNED TO MAP TO YOUR NEEDS MORE THAN 50 STANDARD ASSESSMENT FORMS ARE PROVIDED PLUS YOU CAN CREATE AS MANY OR AS LITTLE ADDITIONAL ASSESSMENTS AS DESIRED Here is a 3 minute video outlining Clinical App youtu.be/rgPSXj-LWoI COMMENCE A ROUTINE ASSESSMENT Steps for commencing an assessment are: Access Clinical App (iPad, tablet, smartphone, PC) by a simple click from an icon representing the domain, e.g. ADL’s, Clinical or Skin Integrity (as per image on the right). Select the specific assessment form within that domain. Select the desired resident from the names presented to you. Note these are displayed based on your role, facility, permissions. You may then elect to have the immediate prior form for that person presented for modifications/update or you may enter a new form from scratch. Enter the observations and submit the form. 1) 2) 3) 4) 5) The system provides extensive capability in terms of creating the questions that form the assessment; currently 9 different question types are available, as per the image at right, plus you may count and total within forms that require a score, e.g. Braden Scale. Basically this means that i.on my Clinical App will mimic your current assessment forms (simple or complex) and present them digitally for remote data capture across your organisation. Clinical App ® my software Clinical and Care Assessments ADLS Clinical Assessments Medication Skin Integrity Care Management Behavioural & Psychological Lifestyle Activities Admin & Admission Select Name Duplicate or Update New Assessment Historical Assessments I Am Finished Assessment Form Watch List Progress Notes

Transcript of CLINICAL CARE • Assessment Forms (Clinical and · PDF fileNote: in this instance an image...

Page 1: CLINICAL CARE • Assessment Forms (Clinical and · PDF fileNote: in this instance an image from a different clinical app setup has been used to show the flexibility of configuring

CLINICAL CARE• Assessment Forms (Clinical and Administrative)• Care Plans (individualised per client and per staff role)• Progress Notes• Watch List for Shift Change Over

Remote data entry for assessments is conducted via the optional add on i.on my Clinical App. This allows you to use your hand held devices and commence assessments at the point of care (as well as the desktop if wanted).

Clinical App is highly flexible and designed to map to your needs. You decide and name the Domains and Assessments, you decide the forms/assessments, you even decide what images you want to use and how many are displayed across a page, e.g. 2,3,4,5,6, etc.

HIGHLY FLEXIBLE, DESIGNED TO MAP TO YOUR NEEDS

MORE THAN 50 STANDARD ASSESSMENT FORMS ARE PROVIDED PLUS YOU CAN CREATE AS MANY OR AS LITTLE ADDITIONAL ASSESSMENTS AS DESIRED

Here is a 3 minute video outlining Clinical Appyoutu.be/rgPSXj-LWoI

COMMENCE A ROUTINE ASSESSMENTSteps for commencing an assessment are:

Access Clinical App (iPad, tablet, smartphone, PC) by a simple click from an icon representing the domain, e.g. ADL’s, Clinical or Skin Integrity (as per image on the right).Select the specific assessment form within that domain.Select the desired resident from the names presented to you. Note these are displayed based on your role, facility,permissions. You may then elect to have the immediate prior form for that person presented for modifications/update or you may enter a new form from scratch.Enter the observations and submit the form.

1)

2)3)

4)

5)

The system provides extensive capability in terms of creating the questions that form the assessment; currently 9 different question types are available, as per the image at right, plus you may count and total within forms that require a score, e.g. Braden Scale.

Basically this means that i.on my Clinical App will mimic your current assessment forms (simple or complex) and present them digitally for remote data capture across your organisation.

Clinical App

®my software

Clinical and Care Assessments

ADLS ClinicalAssessments

Medication Skin Integrity

CareManagement

Behavioural &Psychological

LifestyleActivities

Admin &Admission

Select Name

Duplicate or Update

New Assessment

Historical Assessments

I Am Finished

Assessment Form

Watch List Progress Notes

Page 2: CLINICAL CARE • Assessment Forms (Clinical and · PDF fileNote: in this instance an image from a different clinical app setup has been used to show the flexibility of configuring

CLINICAL CARE• Assessment Forms (Clinical and Administrative)• Care Plans (individualised per client and per staff role)• Progress Notes• Watch List for Shift Change Over

Complete a routine assessment

Once an assessment has been submitted, you are presented with the following options for either capturing further assessments for that person, the same or other assessments for another.

ONCE SUBMITTED THE RECORD IS AVAILABLE IN REAL-TIME FOR REPORTS,ANALYSIS AND FURTHER PROCESING

EMBEDDED ABILITY TO ASSIGN ACTIONS, ESCALATE TO A COMMITTEE, RAISE A RISK,ADD TO QUALITY PLANNING, LINK TO YOUR ACCREDITATION

Your business process may require others to review the submitted assessment prior to it being completed within i.on my care. Should that be the case, that person/approver will receive an alert on submission of assessments they are to review and approve.

When they log in they are presented with an additional button (which you may name) such as in the image on the right, where it is named “Pending Approval List”.

Note: in this instance an image from a different clinical app setup has been used to show the flexibility of configuring this area.

Complete other assessments - such as assessment (wound)Follows the same process as above. Note that you may include images for comparison/rating with your assessment forms such as in the Braden Scale Form on the left.Things to note:(i) The system automatically posts to the form:

the resident’s name and date of birth;name and position of the person capturing the assessment; and the current date (this may be adjusted if required)

(ii) At the time of capturing the assessment, you may add the person (and that assessment with your comments) to the Watch list. This is highly useful for shift changeover and can form the handover notes.

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Record a new assessment for this person

Record a new assessment for another person

Record same assessment for another person

I am Finished

View Watch List

Thank you. Your answers were submitted successfully. As you submitted this publicly, you cannot change your submission

Clinical CareAssessment

ClinicalAssessments

CareManagement

Psychological& Behavioural

Lifestyle

Admissions &Administration

Health & DailyLiving

Select Name

Duplicate or Update

New Assessment

Care Management Review

Pending Approval List

I Am Finished

Assessment Form

Alert Watch Night SniftProgress Notes

Page 3: CLINICAL CARE • Assessment Forms (Clinical and · PDF fileNote: in this instance an image from a different clinical app setup has been used to show the flexibility of configuring

CLINICAL CARE• Assessment Forms (Clinical and Administrative)• Care Plans (individualised per client and per staff role)• Progress Notes• Watch List for Shift Change Over

Generate a Care Plan

Individualised care plans are automatically populated based on your business rules and the results of assessments. Every time an assessment is redone or results amended, the care plan is instantly automatically updated as well.

i.on my care planning offers a truly unique capability of identification and automatic generation of care plans, not only tailored for individuals but tailored for your specialist nursing, carer, lifestyle and hotel positions.

This means you may have i.on my auto generate care plans for your DON, RN’s, AIN’s etc. And where the items in those care plans map to assessments and specified questions and responses within those assessments.

CARE PLANS ARE AUTOMATICALLY UPDATED AS NEW ASSESSMENTS ARE COMPLETED

AUTOMATICALLY GENERATED AND INDIVIDUALISED ICPs BASED ON YOUR BUSINESS RULES

Generate an Interim Care Plan (ICP)

You may either build a specified ICP and assess against that, or create an additional care plan assessment category specifically for your interim care planning needs and have the ICP automatic built. The automatically built ICP would be based on the responses to nominated questions in identified assessment forms.

It is a very simple process to tag a question and response to automatic flow to generated care plans. At the assessment question level you indicate if it is to flow to the care plan, and you then identify which care plan categories it goes to. Below are images of the set up.

Note: this is 100% user defined, so you decide the categories according to your business needs.

This means that either all your ICP questions can be predefined, and you complete an assessment form that is the ICP; or you complete individual specific assessments with tagged questions and responses that auto populate the ICP for you.

Here is a 2 minute video on individualised Care Plans:youtu.be/DAXCY8dtvlY

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Role Based Auto Generated Care Plans

Care Plan - AIN

Page 4: CLINICAL CARE • Assessment Forms (Clinical and · PDF fileNote: in this instance an image from a different clinical app setup has been used to show the flexibility of configuring

CLINICAL CARE• Assessment Forms (Clinical and Administrative)• Care Plans (individualised per client and per staff role)• Progress Notes• Watch List for Shift Change Over

It also ensures that, in real time, as an assessment is conducted that impacts a care needs, the relevant care plan is instantly updated and immediately available to those who care for that person. Naturally the prior plan is posted to history for records management. Accessing the historical plan is managed via a screen filter, as per the image on the left.

IMMENSELY POWERFUL WITH SIGNIFICANT PROCESS IMPROVEMENTS AND TIME SAVINGS

PHOTO, IDENTIFICATION AND ALLERGIES ARE AUTOMATICALLY INCLUDED

Modify a Care Plan

With i.on my automated care planning, care plans are auto updated.

When questions within assessments that have been tagged to form the care plan are assessed/ reassessed, this triggers a care plan update.

This means, for example, that if a specific question such as a diet change on a Nutrition and Hydration Assessment is responded to, and that question and response has been tagged to only go to the hotel staff care plan, then only the hotel staff care plan is auto updated. Thus the updated questions and responses are role sensitive. In this example the change was only applicable to hotel staff, therefore all other care plans remain as previously created.

Print a Care Plan for stakeholders including resident,relative or hospital

Printing individual care plans is as easy as selecting the design desired and clicking an icon that is in the image on the right. Once clicked, all related care plan details are then available, saved as a pdf for printing or sending.

i.on my automatically provides the additional information for the printed care plan of the resident’s photo, ID and allergies.

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Page 5: CLINICAL CARE • Assessment Forms (Clinical and · PDF fileNote: in this instance an image from a different clinical app setup has been used to show the flexibility of configuring

CLINICAL CARE• Assessment Forms (Clinical and Administrative)• Care Plans (individualised per client and per staff role)• Progress Notes• Watch List for Shift Change Over

View resident's chart

i.on my Clinical App assessment forms allow for capturing of charting details – down to hourly observations across a date range.

Basically we recreate your charts using highly flexible tools that provide multiple options for design, such as creating a grid for charting.

CLIENT/RESIDENT, CHARTS PRODUCED ON DEMAND: INDIVIDUAL, FACILITY BASED OR ORGANISATION WIDE

ABLE TO HAVE AUTOMATICALLY DELIVERED REPORTS AND CHARTS TO THOSE WHO NEED TO KNOW WHAT THEY NEED TO KNOW

Questions may be any of the styles in the image on the left.

For charting the usual option here is ‘Likert Scale’, as additional options are provided that result in the build of a grid that can include any or all of the question types displayed in the image on the right within that grid.

Record an observationEasily achieved via assessment entry. This results in automatic collation of reports.

This combination of questions and grid and grid values within questions means we can build charting forms to suit your needs, e.g. behavioural, neurological, pain, bowel, bladder etc.

Once the forms are built and assessments captured, i.on my reports then produce resident charts on demand. These can be individual or by chart type, facility or organisation-wide. They may even be scheduled for daily delivery to those who need to know.

Here is a 3 minute video outlining Clinical Appyoutu.be/rgPSXj-LWoI

®my software

Page 6: CLINICAL CARE • Assessment Forms (Clinical and · PDF fileNote: in this instance an image from a different clinical app setup has been used to show the flexibility of configuring

CLINICAL CARE• Assessment Forms (Clinical and Administrative)• Care Plans (individualised per client and per staff role)• Progress Notes• Watch List for Shift Change Over

To Add progress documentation

Progress notes can be added using clinical app remote data capture or within i.on my core itself.

When users select the appropriate client/resident and click on progress notes, they are presented with a summary list of prior progress notes, plus the ability to enter new information as per the image at the bottom of this page. The information is is real time available to both view and for reports.

You are able to provide external representatives (such as the pharmacist or hospital) with secure access to your clinical app and they are then able (within security permissions you determine) to add progress notes.

PROGRESS NOTES MADE EASY WITH POWERFUL INSTANT REPORTING

ADD ACTIONS, TAP INTO ESCALATIONS MONITORING, ATTACH DOCUMENTATION AND FILES

Once a progress note has been created in clinical app it is available for further processing within i.on my core. For example, you can assign actions and tap into advanced functionality such as key event escalations monitoring – to tightly follow any associated actions and ensure they occur according to your scheduled timings.

Additionally you may upload attachments (e.g. documents, images, audio, video files), plus link the note to material from your centralised library, e.g. policy, procedure, checklist, etc. This is displayed in the image on the left.

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Progress Notes

Page 7: CLINICAL CARE • Assessment Forms (Clinical and · PDF fileNote: in this instance an image from a different clinical app setup has been used to show the flexibility of configuring

CLINICAL CARE• Assessment Forms (Clinical and Administrative)• Care Plans (individualised per client and per staff role)• Progress Notes• Watch List for Shift Change Over

Clients/Residents may be tagged for the ‘Alert Watch’ List. This means that other carers are able to view the watch list and see the nominated person and associated comments, this forming a key part of shift change over.

Automatically included at the end of each assessment form is an “Add to Watch List option and comments field. Once tagged here the client/resident record is instantly added to the watch list.

SHIFT CHANGE OVER STREAMLINED WITH ALERT WATCH TAGGING AND REPORTING

I.ON MY CLINICAL APP: PROVIDING YOU WITH THE KEY PIECES

Here is a 3 minute video outlining Clinical Appyoutu.be/rgPSXj-LWoI

®my software

Alert Watch

Watch Comments:

Add to Watch List