Creating Physician’s Orders

Our new Physician orders, scheduled for release January 2018, supports agencies with managing orders within the Home Health solution.  The new Physician orders provides the ability to easily document and support tracking of all orders entered into the Home Health solution.    The latest updates provide the ability to account for all interventions and orders in the new Medicare Conditions of Participation (CoP). [CoP §484.60 (b)]

Based on the following CoPs:

CoP §484.110 (a) Standard:  Contents of clinical record.   The record must include:

CoP §484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician orders;  COP §484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions;

We have added the following functionality:

  • There are 4 types of orders to enter into the system
    • Medication Orders
    • Plan of Care Orders
    • Discipline Frequency Orders
    • Supply Manager Orders
  • Medication Orders allows the clinician to update orders directly within the Medication Profile and have it flow back to the physician orders.
  • Plan of Care Orders ensures the evolving plan of care orders are always current and allows the clinician to update the Plan of Care orders directly within the POC Orders Profile.
  • Discipline Frequency features the current functionality to add/change discipline frequencies to the Plan of Care
  • Supply Manager is a place to document new supplies/DME as ordered by the physician. This box is the basis for a future supply manager feature to track supplies.
  • Clinician Signature and time of order

Conformance with physician orders are based on the following CoPs:

CoP §484.60(b)(3) states “Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies.”

CoP §484.60(b)(4) states “When services are provided on the basis of a physician’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders.  Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws and regulations, as well as the HHA’s internal policies.”

We have added the following functionality:

  • Ability to document if a copy of the order was sent to the primary care physician in the event the order is given by another physician on the case, if desired.
  • All orders from each box will flow to the Physician Order form once generated.
  • All orders will be reflected within the POC Summary which is the evolving Plan of Care.