Coordination Notes
Coordination Notes are utilized to coordinate care amongst the inter-disciplinary team and are stored within a patient’s Medical Record. Notes can be entered via the Pointcare application by all direct care staff (SN, PT, OT, ST, MSW, HHA) as well as through R2 by office staff. They are viewable by all care team members in the patient’s Medical Record in chronological order.
Notes vary in purpose and intent by the ‘Type’ of note (Narrative, Clinical, Care Coordination, etc.) and certain notes entered by direct care staff will route to Workflow to be reviewed and acted upon by office staff. An example is that a ‘CLINICAL’ note once saved and sync’d by direct care staff will be routed to the Clinical Manager’s workflow to be reviewed. Other notes such as ‘Care Coordination’ will live in the Medical Record as an update and to be seen by all, but do not go to Workflow and thus there is no guarantee this note type will be acted upon or reviewed.
Additionally, certain Note types can automatically appear in the Medical Record based on actions that occurred in documentation, such as when a ‘Missed Visit’ is documented a ‘Missed Visit Notification’ note will automatically generate.
Common Note types, who they are routed to (if routed to back office) and the Purpose of the Notes are listed below:
Note Type | Office Staff Routed To (blank if not routed) | Purpose of Note/Intent |
ADMISSION COORDINATION | To be used by the by the SOC clinician to obtain referral date, SOC ordered date and other information needed to coordinate the admission. The CM will enter this note and include documentation on any verbal orders received. | |
ADVANCE BENEFICIARY NOTICE (HHABN) | Clinical Manager | Documents that a copy of the HHABN was explained to the patient and left in the home. HHABN option # can be inserted in place of *. |
ATTACHMENT NOTIFICATIONS | Clinical Manager | Used to notify the clinical manager if an attachment has been added into HCHB and they need to be aware (Ex. ROC orders / labs ) |
CARE COORDINATION | Used to document care coordination. | |
CASE CONFERENCE | Document inter-disciplinary communication or information discussed during case conference. | |
CLINICAL | Clinical Manager | Field clinicians needing to document clinical information about the patient for the clinical manager to review. |
CLINICAL EXCEPTION | Clinical Manager | If the number of visits exceeds the recommended utilization based on the OASIS assessment this note will have the clinician document the reason for the increased utilization. |
CLINICALLY SIGNIFICANT MEDICATION ISSUE | Clinical Manager | System generated if there is a clinically significant medication issue |
DEMOGRAPHIC CHANGE REQUEST | Office Medical Records | Used to request a demographic change update to the patient's chart, or to document a demographic change was made. |
DISCHARGE SUMMARY | Summarize a patient's discharge. | |
EMERGENCY PLAN REVIEWED | Used to document communication with the patient/caregiver regarding their Emergency Plan. | |
HOSPITAL HOLD INFORMATION | Clinical Manager | Used to document details if patient in the hospital whether or not they have been admitted. |
LATE VISIT DOCUMENTATION | Late Entry documentation on a patient - system generated in order to explain why documentation is outside the date of the visit. | |
MEDICATION INTERACTION | Clinical Manager | Created automatically when a Medication Interaction is identified in PointCare or HCHB. |
MISSED VISIT NOTIFICATION | Automatically generated when a missed visit is documented | |
NARRATIVE | If you could not find a place to document something within the visit note. This will be required at the end of the clinicians SOC. | |
NEED FOR CONTINUED CARE (RECERT) | Used to document justification for Recertification of the patient. | |
NON-ADMIT DETAILS | Intake | Documents the reason a patient was Non Admitted. Routes to intake to notify sales/referral source of the non-admit. |
OASIS Modification Request | Quality Assurance Nurse | If Oasis information needs to be corrected or changed after the visit is synched back to the system, then field staff can use this note to alert the Coding/Quality about those changes. |
ON CALL | Used by On Call staff to alert details of the patient's specific information over the weekend or after hours. Reports are ran for coordination note of Oncall. | |
PAYOR SOURCE CHANGE REQUEST | Authorization coordinator | Request to have the payor source changed for a patient. |
POINTCARE VISIT ALERT | Field Staff prior to Visit | Displays before each visit in Pointcare. Used to display pertinent information pertaining to the patient. The back office will need to inactivate the note to have it no longer populate before each visit. |
POTENTIALLY AVOIDABLE EVENT NOTIFICATION | Clinical Manager | System generated whenever OASIS responses dictate there could be a potentially avoidable event. Will generate wherever the DC or Transfer is being done. |
SCHEDULER NOTIFICATION | PSC | Field staff can use this note type to communicate with the PSC non urgent information. |
SNAPSHOT SN/PT/OT/ST/SW/CH NOTE | Used to document key information and plan needed for patient care between clinicians. This will appear prior to opening the patient's visit for the discipline selected. | |
VISIT TIME CHANGE REQUEST | PSC | Request to change the in-home time on the visit |
VISIT TIME EXCEPTION | PSC | Automatically generated for the clinician to create when either the minimum in home time is not reached or the maximum in home time is exceeded. |