CareAssist User Guide

Transcription

1 CareAssist User Guide

2 MatrixCare CareAssist User Guide This document was written for use with CareAssist 2015 R3. September 2015 MatrixCare is a registered trademark of MatrixCare, Inc. All rights reserved. Other products are trademarks or registered trademarks of their respective holders. This document and the software it represents are the exclusive property of MatrixCare. Information in this document is subject to change without notice. The software described in this document is furnished under a license agreement or nondisclosure agreement. The software may be used or copied only in accordance with the terms of those agreements. No part of this publication may in whole or in part be reproduced, stored in a retrieval system, or transmitted in any form, or any means electronic or mechanical including photocopying and recording for any purpose other than the purchaser s personal use without prior consent, in writing, from MatrixCare. Companies, names, and data used in examples herein are fictitious unless otherwise noted. MatrixCare Hampshire Avenue South Suite 100 Bloomington, MN Support: Support support@matrixcare.com Main: Fax: URL:

3 Table of Contents CareAssist User Guide... i CareAssist... 1 CareAssist System Requirements... 1 Setup... 2 Mapping Heading and Sub-headings... 2 Mapping CareAssist Headings... 2 Mapping CareAssist Sub-headings... 3 Setting Up Employee Positions... 5 Managing CareAssist Users... 5 Adding a User... 5 Managing Users... 7 Setting Up the Shift Master... 7 Setting Up the Shift Time Master... 8 Setting Up the Zone Master... 8 Setting Up the Time Zone... 8 Accessing CareAssist Logging In Changing Your Assignment Changing Your Password Logging Out Using CareAssist Using the My Residents List Using the All Residents List Documenting Resident Tasks Using Resident Tasks Look Back Amending Resident Tasks Charting Marking Resident Tasks Charting Invalid emar About emar Tasks Documenting Orders Scheduled Now Documenting Orders Scheduled Later Documenting As Needed Orders Working with Med Notes Completing Follow Up Tasks Amending and Marking Orders Invalid Approving Orders Rejecting Orders Reconciling Orders Managing Orders in MatrixCare for SNF Viewing Current Orders Careassist Guide i

4 Editing Current Orders Discontinuing Orders Adding Orders Features of Orders Adding a Prescription Order Adding a General Order Reports Resident Level Facility Level Reports Running the Order Import Report Running the POC Task History Report ii Careassist Guide

5 CareAssist MatrixCare CareAssist provides resident care documentation functionality at the point of care in one easy-to-use application focused on meeting the unique needs of Senior Living communities. CareAssist helps you capture care provided, resident tasks, changes and exceptions to care and changes in level of care. CareAssist can help improve workflow, efficiency, quality of care and drive reimbursement for your community. This solution provides the ability to consistently document individualized and resident-centered care and improve caregiver documentation, increase revenue and improve resident and family satisfaction. CareAssist System Requirements The following system requirements are recommended for optimal use with CareAssist: Device Operating System Web Browsers Desktop or Laptop Computer 1440 x 900 resolution recommended, 1024 x 768 resolution minimum Windows 7 (32-bit or 64-bit) Internet Explorer 9, 10, 11; Google Chrome Version 42 or higher Windows 8 (32-bit or 64-bit) Internet Explorer 10, Google Chrome Version 42 or higher Windows 8.1 Internet Explorer 11, Google Chrome Version 42 or higher Windows 10 Internet Explorer 11 ipad, ipad Mini Version 3 and newer Android tablet 7 or larger, landscape orientation OsX 10.8, 10.9, or ios 8 and up Lollipop Google Chrome Version 42 or higher, Safari (current version) Google Chrome Version 42 or higher, Safari (current version) Google Chrome Version 42 or higher Note: When using IE9 or IE10, if you have the Internet Options > Advanced > Security setting for SSL 2.0 selected/enabled, the CareAssist login page might not appear (or appear with an error message). To work around this issue, deselect the SSL 2.0 check box and click Apply. Careassist Guide 1

6 Setup To use CareAssist successfully, ensure setup is complete in the following areas of MatrixCare for Senior Living (MCSL): Headings and Sub-Headings Employee Position Master CareAssist Users Shift Master Shift Time Master Zone Master (optional) Time Zone setup Mapping Heading and Sub-headings You can map the headers and sub-headers you use to build assessments in MCSL to categories and sub-categories that appear in CareAssist for documentation. By mapping the headings and subheadings to CareAssist categories and sub-categories, you can control which tasks appear in CareAssist for documentation (for example, Activities of Daily Living, Nutrition, etc.). Mapping CareAssist Headings To map headings to categories: 1. Log in to MCSL. 2. From the System Setup menu, navigate to the Task Scheduling option and select Category Mapping. The mapping page appears. 2 Careassist Guide

7 3. Select the Assessment Template that you want to map to CareAssist. 4. All Assessment Headers for that template appear in the column on the left. You can begin mapping headers to categories, or select an assessment header from the All dropdown list to map only that header to a CareAssist Category. 5. For each Assessment Header you want documented in CareAssist, select a CareAssist Category to correspond with the assessment header. For example, to prompt CareAssist users to document for the Activities of Daily Living/Physical Functioning assessment header, select Activities of Daily Living from the CareAssist Category column for that header. A CareAssist Category can only be mapped to one Assessment Header, and vice versa. Mapping all assessment headers to CareAssist categories is not required. If you do not want items under a specific assessment header documented in CareAssist, do not map that assessment header to any CareAssist category. 6. Select Save. Mapping CareAssist Sub-headings To map sub-headers to sub-categories: 1. Log in to MCSL. 2. From the System Setup menu, navigate to the Task Scheduling option and select Sub- Category Mapping. The sub-header mapping page appears. 3. Select the Assessment Template that you want to map to CareAssist. 4. From the drop-down list, select the Assessment Header for which you want to associate to sub-categories in CareAssist. For example, to prompt CareAssist users to document for the sub-headers under the Activities of Daily Living assessment header, select the Activities of Daily Living header: Careassist Guide 3

8 5. All Sub-Categories for that Assessment Header appear in the column on the left. For each Assessment Sub-Category you want documented in CareAssist, select a CareAssist Sub- Category to correspond with the assessment sub-header. A CareAssist Sub-Category can only be mapped to one Assessment Sub-Header, and vice versa. Mapping all assessment sub-headers to CareAssist sub-categories is not required. If you do not want items under a specific assessment sub-header documented in CareAssist, do not map that assessment header to any CareAssist sub-category. 6. Select Save. 4 Careassist Guide

9 Setting Up Employee Positions You can set up the employee positions for users in MCSL, such as Caregiver, Activities Staff, Bath Aide, etc. Each user is assigned a position when working in CareAssist. To add a new employee position: 1. Log in to MCSL. 2. From the System Setup menu, navigate to the Task Scheduling option and select Employee Position Master. The Employee Position Master page appears. 3. Select the community from the Community Name drop-down list. 4. Click the Add New button to add a new employee position. 5. Click Edit to update the Employee Position or Employee Position Description. 6. Click Delete to remove an employee position. Managing CareAssist Users You can set up and manage CareAssist users in MCSL. To give an existing MCSL user access to CareAssist, complete the steps below for adding a new CareAssist User. Adding a User To add a new CareAssist user: 1. Log in to MCSL. 2. From the System Setup menu, navigate to the Task Scheduling option and select CareAssist User Management. The CareAssist User Management page appears. 3. Click Add New User. The Add window opens. Careassist Guide 5

10 Note: The Security Questions and Security Answers are selected by the user when the user logs in to CareAssist for the first time, so these fields are grayed out. 4. Enter the following information for the user: First Name Last Name Employee ID User Name Address Cellphone 5. Select the Primary Community for the user from the drop-down list. 6. Select the user s Main Position from the drop-down list. 7. You can select one or two additional positions for that user in the primary community, as necessary, from the Position 2 and Position 3 drop-down lists. 8. To add another community, select the + Secondary button. You can add up to three communities for the user. The Primary Community selected and communities added here are available for the user to select when the user logs in to CareAssist. 9. Select the User-specific security tokens to determine what areas the user will be able to access in CareAssist. 10. Select Save. 11. A message appears indicating you have successfully added the user, including the username and the user s temporary password. Important: Make note of the temporary password so you can notify the user of the user s initial login information. When the user logs in for the first time, the user will be required to select security questions and answers and change their password. 12. Select the Close button. 6 Careassist Guide

11 Managing Users From CareAssist User Management, you can update user information, unlock users, reset usernames and passwords, delete users, and inactivate or reactivate users. To manage CareAssist users: 1. Log in to MCSL. 2. From the System Setup menu, navigate to the Task Scheduling option and select CareAssist User Management. 3. The CareAssist User Management page appears. You can click the column headings to sort the users for example, you can click the Primary Community column to sort for users in a specific community, or the Main Position column to find users with a specific main position. 4. Once you find the user you want to update, click the box in the Date & Time column. The user s row is then highlighted and the applicable buttons at the top of the page are enabled: You can then complete the following actions for the user Select the Modify button to update information about the user, such as address or primary community. Select the Unlock button to unlock the user. This button is only available for users with a Status of Locked. A user becomes locked after entering the wrong password three times in a row. Select the User Name Reset button to change the user name. Select the Password Reset button to reset the user s password. Selecting the Reset Password button will prompt the user to answer one of their security questions correctly and reset their password. Select the Delete button to delete a user. A confirmation window opens from which you can select Delete User to delete the user or Close to close the window without deleting the user. Deleting a user immediately and permanently terminates the user s access to CareAssist. Select the In-Activate button to make a user temporarily inactive, terminating the user s access to CareAssist. For inactive residents, the Re-Activate button is available to re-activate the user so the user can access CareAssist. Setting Up the Shift Master The Shift Master Setup is used to set the number of shifts per position. 1. Log in to MCSL. Careassist Guide 7

12 2. From the HR menu, select Task Scheduling, then Shift Master. The Shift Master screen appears. 3. In the Community Name list, select the community. 4. In the Category list, select the category. 5. Set up the shifts for the employee positions. Setting Up the Shift Time Master The Shift Time Master is used to set the times for each shift per position. 1. Log in to MCSL. 2. From the HR menu, select Task Scheduling, then Shift Time Master. The Shift Time Master screen appears. 3. In the Community Name list, select the community. 4. In the Category list, select the category. 5. In the Position list, select the position. The screen refreshes and the Shift Type data appears. 6. Set up the shifts times for the community, category, and employee positions. Setting Up the Zone Master To set up zones, perform the following steps: 1. Log into MCSL. 2. From the System Setup menu, select Task Scheduling, then Zone Master. The Zone Master screen appears. 3. To add a zone, click the Add button. The Zone Master window appears. 4. In the Community Name field, select the community from the list. 5. In the Employee Position field, select the position from the list. 6. In the Zone Name field, enter the new zone name. 7. In the Category field, select the category. 8. In the Shifts field, select the shift. 9. In the Apartments field: Click inside the field to see a list of apartments. Select the check boxes for the apartment numbers to be included in the zone, or click Select All if desired. Click outside the apartment list to dismiss it. 10. Click Save. Setting Up the Time Zone The Time Zone Setup is used to set the local time zone for communities. 1. Log into MCSL. 8 Careassist Guide

13 2. To set (or verify) the Time Zone, from the System Setup menu, select Census, then Community Setup. 3. Select the community you want to change, and click the Edit button. The Community Setup screen for the selected community appears. 4. In the right column, locate the Time Zone field. 5. Verify the Time Zone is set correctly. If necessary, change it by selecting the correct time zone from the list. 6. When finished, click Save. A preview of the changes appears. 7. Ensure the change was made, then click Close. Careassist Guide 9

14 Accessing CareAssist Logging In To log in to CareAssist: 1. Enter your User Name and Password. 2. Select Login. 3. If this is your first time logging in to CareAssist, the Set A New Password window appears. 4. Select security questions and enter security answers for the three security question and answer fields. Note that each security question must be unique. 5. In the Old Password field, enter the temporary password you were assigned. 6. Enter a New Password. As you enter the new password, the password guidelines listed at the right automatically update to indicate if your password meets the requirements. 7. Enter that password again in the Confirm New Password field. 10 Careassist Guide

15 8. Select Save. 9. The CareAssist login page appears with a message indicating you successfully created your new password. 10. Log in to CareAssist with your username and newly created password. Note: If you enter your password incorrectly three times in a row, your account will be locked. The Select Community, Care Setting, Shift, and Assignment window appears. 11. Select the community in which you are working. The communities that appear are those assigned to you in MCSL. 12. Select the care setting in which you are working, for example, Assisted Living or Memory Care. 13. Select one or more shifts. The shifts appear according to the community and care setting you selected and the employee positions set up for you in MCSL. Careassist Guide 11

16 14. Select Next. 15. If you have multiple positions, select your assignment (Caregiver, Activities Staff, etc). 16. If your community has zones defined for the position you selected, select your zone. 17. Select Start. Changing Your Assignment To change the community, care setting, shift and/or assignment in which you are working: 1. Select the down arrow icon at the top of the screen. 2. Select the Change Assignment link. The Select Community, Care Setting, Shift and Assignment window opens. Your currently selected Community, Care Setting, Shift and Assignment remain selected. 3. You can select additional assignments and/or deselect currently selected assignments (highlighted green). 4. To change your community or care setting, select Start. 5. To continue without changing your community or care setting, select Back. Changing Your Password To change your CareAssist password: 1. Select the arrow icon at the top of the screen. 2. Select Change Password. 3. The Change Password window opens. 4. Enter your old or temporary password in the Old/Temporary Password field. 12 Careassist Guide

17 Logging Out Note: If you enter your Old/Temporary Password incorrectly three times in a row, you will not be able to change your password and your account will be locked the next time you try to log in. You will need to contact your security administrator to either unlock your account or reset your password. 5. Enter a New Password. 6. Enter the new password again in the Confirm Password field. 7. Select Save. To exit CareAssist, select the arrow icon at the top of the screen, then select Logout. Logging out clears any added residents from your list and does not retain any assignment selections such as community or shift. Automatic Logout If you have not been actively working in CareAssist for more than 2 minutes, a warning message appears noting that your session will expire in 30 seconds. You can select Yes, continue to continue working in CareAssist or Logout to exit CareAssist. If you do not select Yes, continue or Logout in the time remaining, CareAssist logs you out automatically and any unsaved documentation is not saved. Careassist Guide 13

18 Using CareAssist Using the My Residents List If your community uses zones, the My Residents list appears when you log in to CareAssist and select your community, care setting, shift, assignment and zone. Note: If your community does not use zones, the All Residents list appears. Residents currently out of the community on a short break appear grayed out and you cannot select them. To search for a resident, type the resident's name or apartment number in the Search Resident field and click the magnifying glass button. You can sort the search results using the Sort drop-down list. You can add another resident to your list by selecting the Add Resident button. You can view a list of all residents by selecting All Residents on the left side of the page. You can select Manage My Residents from the top of the page to navigate to the My Residents list again. If a resident in your My Residents list has an emar order administration entered as STAT (considered due immediately or as indicated in the frequency), a red STAT indicator appears above the emar menu option. To add a resident to your list: 1. Select the Add Resident button from the My Residents page. 2. The Add Resident window opens. All residents not already in your My Residents list appear. Residents currently out of the community appear grayed out and you cannot select them. 14 Careassist Guide

19 3. You can search for residents from this window by entering a resident name or part of a name in the text box in the upper-right corner of the window. 4. Select the Add to My Residents button for one or more residents to add to your list. The button turns green with a check mark and reads Added once selected. You can select the Added button to deselect the resident again. 5. Select the Done button to add the selected resident(s) to your list. Or, select Cancel to return to your list without adding any residents. Note: When you add a resident to your list in CareAssist, the resident(s) remain on your list until you log out or change your community. 6. The residents you added appear on the My Residents list with an X icon in the upper right corner of the resident button. To remove a resident from your list: 1. Select the X icon for the resident you added to remove him/her from your list. When you select the X icon, a warning message appears. 2. Select OK to remove the resident or Cancel to keep the resident on your list. Note: In CareAssist, you can only remove residents you added to your list. Using the All Residents List If your community does not use zones, the All Residents list appears when you log in to CareAssist and select your community, care setting, shift and assignment. Note: If your community uses zones, the My Residents list appears. Careassist Guide 15

20 To search for a resident, type the resident's name or apartment number in the Search Resident field and click the magnifying glass button. You can sort the search results using the Sort drop-down list. Residents currently out of the community on a short break appear grayed out and you cannot select them. You can view all residents at any time by selecting the All Residents button from the left side of the page. Documenting Resident Tasks To document resident tasks: 1. Select the resident from the My Residents list or All Residents page. The Resident Charting page appears. At the top of the page, the resident name and photo (if uploaded in MCSL) appear, along with other vital resident information such as advance directives, allergies and diagnoses. You can also select the service plan icon on the right to review the resident s service plan from MCSL. The service plan opens in a pop-up window for your reference. Note: If the resident does not have a service plan in MCSL when you select the service plan icon, a message appears stating that the service plan is not available. Resident care task categories appear below according to the assessment headings mapped to CareAssist categories in MCSL. 2. Select a category. 3. The corresponding subcategories appear, according to the assessment sub-headings mapped to CareAssist sub-categories in MCSL. The date and time the task was last charted appear on the sub-category buttons. 16 Careassist Guide

21 4. Select a subcategory. A documentation window opens for that subcategory. Any notes from the resident's most recent Negotiated Service Plan (NSP) in MCSL for that item appear for your review. 5. Select Complete, Complete with Exception, or Not Complete. If you select Complete with Exception or Not Complete, you must select an Exception Reason or a Not Complete Reason. 6. In the Minutes of Service field, enter the number of minutes you spent completing the task (optional). 7. Enter any Comments (optional). You can enter up to 500 characters. As you type, the character counter on the right updates to indicate how many more characters you can enter. 8. Select Complete. Or, select Cancel to exit the window without saving. To document for another resident: 1. Select the > icon on the left. The residents in your My Residents list appear. Residents with a dashed-line border and exclamation mark (!) have STAT emar order administrations. Residents with a blue dot icon have order administrations due Residents with a purple bell icon have order administration follow-up tasks 2. You can select the < icon to hide the list of residents again without selecting a resident. 3. To keep the My Residents list open as you work in CareAssist, select Pin. You can select Unpin to hide the list of residents again. 4. Select the appropriate resident. Or, to document on a resident not in your My Residents list, type a resident s name in the Find a Resident field and press Enter to search for a resident from the list of all residents and add the resident to your list. Note: If no resident is selected when you navigate to the Resident Tasks page, a message that reads Please select a resident from the left appears in place of the resident information at the top of the page. Using Resident Tasks Look Back You can view previous responses for resident charting in CareAssist by selecting the Look Back button on the Resident Charting page. When you select Look Back, the charting history from the last 48 hours appears for that resident, including the date/time recorded, the user who recorded the data, and response information. The charting history is sorted by Date/Time by default. Alternatively, you can select the following column headers to sort the information accordingly: User Category Task Completed Careassist Guide 17

22 You can use the look back information to review the resident's most recent charting history and determine if the current resident tasks charting needs to be adjusted accordingly. If you have appropriate security, you can amend and/or mark invalid resident tasks charted by you. Resident tasks marked invalid do not appear on the Resident Charting Look Back page. Amending Resident Tasks Charting From the Resident Charting Look Back page, you can amend charting data entered by you if you have appropriate security. To amend resident tasks charting: 1. Select the Look Back button on the Resident Charting page. The Look Back page appears. 2. Select the Amend link in the Action column for the task you would like to amend. 3. The Amend Task window opens. The resident task charting details appear along with the service plan notes for that item. 4. Update the task as needed. 5. Select an Amend Reason. 6. Select the Amend button. Or, select Cancel to close the window without amending the task. 7. The updated task information appears on the Resident Charting Look Back page. Marking Resident Tasks Charting Invalid From the Resident Charting Look Back page, you can mark invalid charting data entered by you if you have appropriate security. To mark invalid resident tasks charting: 1. Select the Look Back button on the Resident Charting page. The Look Back page appears. 2. Select the Mark Invalid link in the Action column for the task you would like to amend. 3. The Mark Task Invalid window opens. Review the resident task charting details. 4. Select an Invalidation Reason. 5. Select the Mark Invalid button. Or, select Cancel to close the window without marking the task charting invalid. 6. The task you marked invalid no longer appears on the Resident Charting Look Back page. 18 Careassist Guide

23 emar About emar Tasks The emar Tasks page features orders for a resident organized by tabs: Scheduled Now, Scheduled Later, and As Needed. Medications on each of these tabs appear organized by time, earliest due to latest due. At the top of the page, the resident name and photo (if uploaded in MatrixCare for Senior Living) appear, along with other vital resident information such as advance directives, allergies and diagnoses. You can also select the service plan icon on the right to review the resident s service plan from MatrixCare for Senior Living. The service plan opens in a pop-up window for your reference. Note: If the resident does not have a service plan in MatrixCare for Senior Living when you select the service plan icon, a message appears stating that the service plan is not available. If a resident in your My Residents list has an emar order administration entered as STAT (considered due immediately or as indicated in the frequency), a red STAT indicator appears above the emar menu option. A bell icon indicates follow up tasks are required. From this page, you can review the resident's emar tasks, including drug, amount, form and route information along with any additional instructions. You can click anywhere in the medication box header to view additional details about the order and enter any med notes such as vital signs, if necessary. You can also mark the medication as prepped, given, or not given. Documenting Orders Scheduled Now You can document order administrations that are scheduled now as given from the Scheduled Now tab on the emar Tasks page. If an order appears as Due 8:00 A.M., CareAssist prompts you to give the Due order for 1 hour before and 1 hour after that time. Therefore, the order is Due between 7:00 A.M. and 9:00 A.M. Prior to 7:00 A.M. the order will be Early, and after 9:00 A.M. the order will be Late. If an order has an administration time range, for example Due 8:00 A.M. 10:00 A.M., CareAssist prompts you to give during the exact time range of the Due order. Therefore, the order is Due between 8:00 A.M. and 10:00 A.M. There is no hour before/after in this scenario. Prior to 8:00 A.M. the order will be Early and after 10:00 A.M. the order will be Late. Orders entered as STAT, which are due immediately, appear in orange with a dashedline border. Orders that are Late appear in red with a red border. To mark that a medication is prepared: Careassist Guide 19

24 1. Select Prep. 2. The Prep button turns blue to help keep track as orders are prepared. After you give a resident a medication: 1. Select Given. 2. The Given button turns green to help keep track of orders given. Note: If you are giving the medication late, a Given Late Reason window opens. Select a Given Late Reason, enter a Comment (this field is required for a Given Late Reason of Other, and optional for all other reasons), and select Done. To mark that a medication has not been given: 1. Select Not Given. 2. A Medication Administration window opens. Select a Not Given Reason. 3. Enter an optional Comment. If you select Other as the Not Given Reason, a comment is required. 4. Select Done. The Medication Administration window closes, the Not Given button turns red, and the Not Given Reason you selected appears in the administration box. 5. Select Save. Tips: To mark all prepped medications as given in one step, select the All Prepped Given button. To mark all medications as not given in one step: 1. Select the All Not Given button. 2. A Medication Administration window opens. If the resident has more than 10 medications scheduled now, you can select the Show More link to view the full list of medications. 3. Select a Not Given Reason. 4. Enter a Comment. If you select Other as the Not Given Reason, a comment is required. 5. Select Done. Note: You can mark an order as Prep and Not Given if the resident does not end up taking the medication after you have already prepared it. The Not Given Reason will apply to all medications. 20 Careassist Guide

25 Documenting Orders Scheduled Later You can document order administrations that are scheduled later as given from the Scheduled Later tab on the emar Tasks page. If an order appears as Due 8:00 A.M., CareAssist prompts you to give the Due order for 1 hour before and 1 hour after that time. Therefore, the order is Due between 7:00 A.M. and 9:00 A.M. Prior to 7:00 A.M. the order will be Early, and after 9:00 A.M. the order will be Late. If an order appears Due 8:00 A.M. 10:00 A.M., CareAssist prompts you to give for the exact time range of the Due order. Therefore, the order is Due between 8:00 A.M. and 10:00 A.M. There is no hour before/after in this scenario. Prior to 8:00 A.M. the order will be Early and after 10:00 A.M. the order will be Late. To mark that a medication is prepared: 1. Select Prep. 2. The Prep button turns blue to help keep track as orders are prepared. After you give a resident a medication: 1. Select Given. 2. Since you are giving the medication early, select a Given Early Reason. 3. Enter a Comment, if necessary, and select Done. 4. The Given button turns green to help keep track of orders given. To mark that a medication has not been given: 1. Select Not Given. 2. A Medication Administration window opens. Select a Not Given Reason. 3. Enter a Comment, if necessary. If you select Other as the Not Given Reason, a comment is required. 4. Select Done. The Medication Administration window closes and the Not Given Reason you selected appears in the administration box. 5. Select Save. Tips: To mark all prepped medications as given in one step, select the All Prepped Given button. Documenting As Needed Orders You can document order administrations that are scheduled as needed from the As Needed tab on the emar Tasks page. To mark that a medication is prepared: Careassist Guide 21

26 1. Select Prep. 2. The Prep button turns blue to help keep track as orders are prepared. After you give a resident a medication: 1. Select Given. The As Needed Reason window opens. 2. Select an As Needed Given Reason. 3. Enter a Comment, if necessary. If you select Other as the As Needed Given Reason, a comment is required. 4. Select Done. The As Needed Reason window closes and the Given button appears green to help keep track of orders given. 5. Select Save. To mark that a medication has not been given: 1. Select Not Given. 2. A Medication Administration window opens. Select a Not Given Reason. 3. Enter a Comment. If you select Other as the Not Given Reason, a comment is required. 4. Select Done. The Medication Administration window closes and the Not Given Reason you selected appears in the administration box. 5. Select Save. Working with Med Notes If med notes (vital signs) are required for orders, they will appear at the beginning of the list of orders. Med notes required before you administer an order also appear below the order s special instructions and the Given button is grayed out. Once you enter the indicated med note, the Given button will be enabled. To add or edit a med note: 1. Click the Add/Edit Med Notes link for the order administration. The Order Administration window opens with the med notes required for that administration. 2. Enter and update the required med notes. You can also select Prep, Given, and/or Not Given from this window. 3. Select Done. The med note data appears on the order administration. Completing Follow Up Tasks Follow up tasks appear on the Scheduled Now tab for order administrations marked as given from the As Needed tab. A bell icon on the emar menu indicates follow up tasks are required. To complete a follow up task and document the results of the as needed order administration: 1. Select the Follow Up button for the follow up task listed on the Scheduled Now tab. 2. Select a Follow Up Result. 22 Careassist Guide

27 3. Enter any Comments, as necessary. 4. Select Done. 5. Select Complete. Amending and Marking Orders Invalid You can amend or mark invalid emar documentation, including amending med note documentation, if you have the appropriate security. If you need to amend or mark invalid an emar documentation item: 1. From CareAssist emar, click the emar tab and select Current Orders. 2. Log in to MatrixCare for SNF. 3. Search for and select the resident. 4. On the Current Orders page, scroll to the bottom of the page and click the Amend orders link. 5. Search for and select the order for which you need to amend or mark invalid the documentation. Enter the Start and End date range for the administration which needs to be corrected. Select Prescription in the Order Type drop-down list. Click the Search button. Find the Order that needs to be corrected and click the Amend link. 6. On the Administration History page, find the administration that needs to be corrected and click the Amend Link. 7. On the Amend Administration page select the Amend Reason. 8. Enter an Amend Note. 9. Select the appropriate check boxes to represent the correct action(s). 10. Select the correct radio buttons to explain the circumstances of the changes being made. 11. If changes are made to med notes, select the link to make changes and enter corrections and correction reasons as needed. 12. Click Save. Approving Orders You must approve orders so that they appear as available emar tasks from the emar menu. If imported orders are awaiting approval, an RX icon appears on the emar menu. To approve an order: 1. From the emar menu, select the Order Approval option. Careassist Guide 23

28 2. The Approve Orders page appears with a list of residents who have orders requiring approval/reconciliation. 3. Select the resident's name to expand the list of orders for that resident. 4. Review the order information, such as Start Date, End Date, Drug, Frequency, Administration Time, Instructions, and Medication Assistance. 5. From the Action column, click Approve to approve a single order. The Approve Order window opens with the details of the order. Select Yes to approve the order or No to close the window without approving the order. Rejecting Orders You can reject imported orders so that they do not appear as available emar tasks from the emar menu. If imported orders are awaiting approval or rejection, an RX icon appears on the emar menu. To reject an order: 1. From the emar menu, select the Order Approval option. 2. The Approve Orders page appears with a list of residents who have orders requiring approval/reconciliation. 3. Select the resident's name to expand the list of orders for that resident. 4. Review the order information, such as Start Date, End Date, Drug, Frequency, Administration Time, Instructions, and Medication Assistance. 5. From the Action column, click Reject to reject a single order. The Reject Order window opens with the details of the order. 6. Select a Given Reject Reason. 7. Enter a Comment regarding your reason for rejecting the order. 8. Select Reject to reject the imported order or Cancel to close the window without rejecting the order. Reconciling Orders If a draft order is the same as an imported, unapproved order, you can merge the two together. This will discontinue the draft order and approve the imported order, which is then scheduled on the emar. To reconcile orders: 1. Select the Order Approval option from the emar menu. 2. The Approve Orders page appears with a list of residents who have orders requiring approval/reconciliation. 3. Select the resident's name to expand the list of orders for that resident. 4. From the Draft Orders section, click Reconcile. The Reconcile Orders page displays the draft order in the Draft Order section at the top. The imported, unapproved orders that you can merge with this draft order are listed in the lower half of the page. 24 Careassist Guide

29 5. Review the order information, such as Start Date, End Date, Drug, Frequency, Administration Time, Instructions, and Medication Assistance. If everything matches between the draft order and the imported unapproved order, select the radio button next to the order matching the draft order and click Next. 6. Select Reconcile to merge the order. Once the orders are merged, the imported order is automatically approved and is scheduled on the emar. The draft order is discontinued and sent to history. Careassist Guide 25

30 Managing Orders in MatrixCare for SNF MatrixCare supports pharmacy-centric order entry, which is a uni-directional message order process where the pharmacy receives the original, signed order from the prescriber, enters this order into their software, and sends the order information to the MatrixCare system. Imported orders display on the CareAssist Approve Orders page to be approved. Once an order is approved, it is available to the emar (electronic medication administration record) scheduler and users can document administrations in CareAssist emar. In addition, users with appropriate security can enter draft orders in MatrixCare for SNF to enable documentation of medication administration assistance before an order is imported from the pharmacy. Draft orders can be reconciled with the imported order once the pharmacy sends the order to MatrixCare. If orders need to be modified, for example, to change the administration time or to add a med note for documentation in emar, a user with proper security may edit imported or active orders. Similarly a user with proper security may discontinue an active order if it is needed. Viewing Current Orders To view a resident's current orders: 1. Select Current Orders from the emar menu. 2. Log into MatrixCare for SNF with your user name and password. 3. From the Resident menu, select Search Resident. 4. Enter search criteria (for example, last name) to find the resident you are working with, and then click Search. 5. From the search results, select the resident. The Current Orders page appears and lists the resident's current orders. Editing Current Orders If you need to edit an imported order: 1. Select Current Orders from the emar menu. 2. Log into MatrixCare for SNF with your user name and password. 3. From the Resident menu, select Search Resident. 4. Enter search criteria (for example, last name) to find the resident you are working with, and then click Search. 5. From the search results, select the resident. The Current Orders page appears. 6. Click the order you want to edit. On the View Prescription Order page, scroll to the bottom and select the Edit button. 7. Make your necessary changes and click Save. 26 Careassist Guide

31 Discontinuing Orders If you need to discontinue an active order: 7. Select Current Orders from the emar menu. 8. Log into MatrixCare for SNF with your user name and password. 9. From the Resident menu, select Search Resident. 10. Enter search criteria (for example, last name) to find the resident you are working with, and then click Search. 11. From the search results, select the resident. The Current Orders page appears. 12. Find the order you need to discontinue and click the DC link in the right column. The DC Prescription Order/DC General Order page appears. 13. Complete the following fields to discontinue the order: DC Received Date and DC Received By (default to current date and user), DC Date and DC Time (default to current date and time), DC Ordered By (defaults to the ordering prescriber), Send Change Fax (defaults per facility setup). Note: The DC Reason and DC Note are optional. 14. Sign the discontinued order. If you are authorized to mark orders as signed, the Prescription Order/General Order page will include an additional Order Signatures section. Select the Order Signed on Paper and Original DC Signed on Paper check boxes and click Save. If you are authorized to sign electronically, click Sign DC of Original Order and click Sign at the bottom of the page. Only physicians and NP/PAs can sign electronically. Note: If you have permissions to verify orders, clicking Save or Sign verifies the DC of the order. If you do not have verification permissions, the Current Orders page indicates that the DC of this order requires verification. 15. The View <Type of Order> Order page appears. Note: If this order was marked as "signed" in error and you have security access to unsign the order, click the Unsign button. 16. Click Back to return to the Current Orders page. 17. Click the Search order history link. The Order History page appears. 18. Click Search. A list of discontinued orders appears. 19. To view the order, click the order description link. If you marked the order as signed on paper, the following statement is displayed in the Signature field: "There is a paper signature on file for this order." The Signed By physician and Signed Date are also displayed. If you signed the order electronically, the physician signature is displayed in the Signature field. The Signed By physician and Signed Date and time are also displayed. Careassist Guide 27

32 If the order has been verified, the DC Verified By and DC Verified Date fields display that information, otherwise Awaiting Verification appears in these fields and the DC of the order must be verified. Adding Orders There are multiple types of orders that can be entered in MatrixCare for SNF. The two that you may want to enter for CareAssist are: Prescription orders are used for any medication or product which will be filled by the pharmacy and for products which come from the pharmacy but are facility stock products. General orders (also called ancillary orders) are orders which do not require a pharmacydispensed product. See the following sections for instructions on entering draft prescription orders and general orders in MatrixCare for SNF. Features of Orders Prescription drugs can be searched by brand name, generic name, both (brand name and generic name), or the generic equivalent from a complete drug database. Approving Orders = Verifying Orders. Orders can be approved (verified) in CareAssist on the Approve Orders page and they can be verified in MatrixCare for SNF on the Current Orders page. Verification of orders can be done on the Verify Order page, based on security permissions. Flow sheets: You should assign ALL orders to the medication flow sheet so they appear for documentation in emar. Order History Search: The order history search allows you to search for historical orders using the Start Date and End Date fields. Additionally, you can select whether or not to include active orders. Orders should be marked as Signed on Paper since the original order has been signed outside of the MatrixCare system. Adding a Prescription Order To add a draft prescription order for CareAssist: 1. Log in to MatrixCare for SNF. 2. From the Resident menu, select Orders. If you do not have a resident selected, the Search Residents page appears so you can select a resident. The Current Orders page appears. 3. Click Add Order. The New Order page appears. 4. Select Prescription from the drop-down list in the Type field. 5. Select a Provider from the drop-down list. This field auto-populates with the pharmacy provider selected in the resident face sheet. 28 Careassist Guide

33 6. Leave the Associated Event field blank. 7. Click Next. The Search Prescriptions page appears. 8. Enter the Drug Name. Note: If the desired drug is not listed, you can add a custom drug by clicking Add Custom. The Prescription Order page appears for entering the custom order. 9. Enter the drug name click Search. The Drug Search Results appear at the bottom of the Drug Search page. 10. From the Drug Search Results, select the desired drug. The Prescription Order page appears. 11. Enter the prescription information. The following fields are required: Received Date Received By Start Date and End Date (if not an open-ended order) Drug Name Form Strength Route Frequency Flow Sheet Order Source The Diagnosis and Category fields should be left blank. If you have the Customize Drug security token, you can edit certain parts of the order as selected from the formulary by checking the Customize box. When you select Customize, the Drug Name, Drug Class, Form, Strength, and Route fields become editable. 12. Click Next. The Confirm Prescription Order page appears. From here you can select to cancel, modify, save and return to the Current Orders page or save and new to return to the Add Order page. 13. Select the Order Signed on Paper check box and click Save. The Current Orders page returns and displays the prescription you just ordered in the list of active orders. Adding a General Order To add a draft general (ancillary) order for CareAssist 1. Log in to MatrixCare for SNF. Careassist Guide 29

34 2. From the Resident menu, select Orders. If you do not have a resident selected, the Search Residents page appears so you can select a resident. The Current Orders page appears. 3. Click Add Order. The New Order page appears. 4. Select General from the drop-down list in the Type field. 5. Leave the Associated Event field blank. 6. Click Next. The General Order page appears. 7. Enter the order information. The following fields are required: Received Date Received By Start Date and End Date (if not an open-ended order) Order Description Frequency Category Flow Sheet Ordered By and Order Source The Category and Diagnosis fields should be left blank. 8. Click Next. The Confirm General Order page appears. From here you can select to cancel, modify, and save to return to the Current Orders page or save and new to return to the Add Order page. 9. If this is a physician order, select the Order Signed on Paper check box. 10. Click Save. The Current Orders page returns and displays the general order you just completed in the list of active orders. Reports The following reports are available in MatrixCare for SNF. To learn more about these reports, click the Help link from within MatrixCare for SNF: Resident Level emar: o Resident Administration History Flowsheets o Flowsheet for a Resident Blank 30 Careassist Guide

35 o Flowsheets for a Resident Orders o Physician Orders Resident Info o Resident Face Sheet Facility Level emar: o Administration Compliance o Administration Count o Facility Administration History o PRN Administration History (As Needed medication administration history) Flowsheets o Facility Monthly Flowsheets HIPAA Audit o API Audit Log o PHI Audit Log Orders o Order Report by Drug Class o Physician Orders o Physician Orders Missing ICD-10 o Resident Orders Resident Info o Resident Bed Listing o Resident Face Sheet Security o Account Lockouts Report o Active/Inactive Users Report o Auto Logoffs Report o Invalid Passwords Report o Last Active Login Report o Password Resets Report o Security Maintenance Changes Report o Security Templates Careassist Guide 31

36 Reports Running the Order Import Report An Order Import Report is available in MatrixCare for SNF for reviewing imported orders and the corresponding actions taken for those orders. To run the Order Import Report: 1. Log in to MatrixCare for SNF. 2. From the Facility menu, select the Reports option. The Facility Reports page appears. 3. In the Orders category, select Order Import. 4. Select Next. The Report Parameters page appears. 5. In the Start Date field, enter a date or select one using the Calendar feature. 6. In the End Date field, enter a date or select one using the Calendar feature. 7. Select one or more Order Types to include on the report. 8. From the Order Status drop-down list, select Approved Orders or Rejected Orders. 9. Select one or more Residents from the list. 10. Check Include Inactive Residents (optional). 11. From the Sort By drop-down list, select Import Date, Approved/Rejected Date, Resident Last Name, or Order Type. 12. For the Report Output Type, select PDF or MS Excel. 13. Select Report. The report opens in a new window. You can save or print it, as needed. Running the POC Task History Report A POC Task History Report is available in MCSL for tracking completed tasks documented in CareAssist. To run the POC Task History Report: 1. Log in to MCSL. 2. From the Reports menu, Clinical option, select POC Task History Report. The report criteria page appears. 3. In the Start Date field, enter a date or select one from the drop-down menu. 4. In the End Date field, enter a date or select one from the drop-down menu. 5. From the Community drop-down list, select one or more communities. The communities that appear in the list are those assigned to you. Note: Once you select a Community, the items in the Category, Position, Caregiver and Resident lists update to reflect choices available only in the selected communities. 32 Careassist Guide