Allegheny Messages

Software updates related to documentation enhancements supporting comprehensive assessment collaboration are available with Main Office Software version 6446 and Clinical Point of Care Software version 2778.
The OASIS Guidance manual states in Chapter 1 under the heading Comprehensive Assessment and Plan of Care: “Agencies may have the comprehensive assessment completed by one clinician. If collaboration with other health care personnel and/or agency staff is utilized, the agency is responsible for establishing policies and practices related to collaborative efforts, including how assessment information from multiple clinicians will be documented within the clinical record, ensuring compliance with applicable requirements, and accepted standards of practice.”…“For items requiring patient assessment, the collaborating healthcare providers must have had direct contact with the patient.”

Software enhancements include adding the new GG items to the Therapy Assessments and Progress notes allowing Therapists and the individual completing the comprehensive assessment the opportunity to collaborate. The GG items available in the Therapy Assessments and Progress notes will not populate the items in the Comprehensive OASIS assessment.
All documented responses are available in the Print Form and View screens for the records.
The Print form of Comprehensive OASIS Start of Care and Resumption of Care will include a list at the top of all of the Visits with Employee and Discipline that occurred from the SOC or ROC date up to and including the M0090 date. The Recertification OASIS print form will contain a list of visits for the 7 days prior to the M0090 date.
The Trend button (represented as a peach colored button with a picture of a white piece of paper) available at the top of comprehensive documents in the Clinical Point of Care software will contain a new option GG items. The Discharge Goals established in the GG items will be available for evaluation of patient progress in meeting the discharge goal established in the Comprehensive OASIS.

As stated in the Guidance manual Agencies are responsible for specific policies and procedures to reflect collaboration practices. These software Enhancements are meant to assist agencies in meeting collaboration practices but do not establish or endorse specific policies or procedures.