Skilled Nurse Visit Notes now include a validation feature to improve the accuracy and quality of physical assessment documentation, reducing time spent on QA processes.
When completing a Skilled Nurse Visit Note, selected abnormalities will be outlined in red, alerting the assessing clinician to select at least one descriptor to correspond with the selected abnormality. These validations will ensure that abnormalities are appropriately documented.
If a user attempts to complete a Skilled Nurse Visit Note with unresolved validations, an error message will prompt the user to provide a response for each section outlined in red before completing the note.
This feature has been released on web and mobile applications.
Aide Visit Notes labeled with (Generated Tasks) include only tasks assigned in the Aide Care Plan. These include:
When an aide performs one of these visits, all assigned items must be addressed.
When a "parent" item is marked as Completed, a required "child" item appears. The aide must enter a value in the child item field before completing the visit. When Refused or N/A is selected for a parent item, a child item is not required.
For example, if the aide indicates that the Pulse Rate (parent) task was completed, a value must be entered indicating the Pulse Rate (child) before completing the visit.
If a user attempts to complete the visit without answering a child question, an error message will prompt the user to provide a response for each section outlined in red before completing the note.
Validations for Skilled Nurse Visit Notes and Aide Visit Notes are initial stages toward implementing complete QA automation in Axxess systems. Introducing automation updates in phases will allow users to progressively develop optimal documentation habits to improve their visit notes without adding cumbersome narratives.