Barnestorm has care plans for Hospice with standardized nomenclature - NOC and NIC codes that have indicators that lead into the QAPI. Barnestorm has licensed these national standard codes from Mosby to help our customers embrace these best practices.
For each problem, there is a list of suggested NIC and NOC codes associated with it specifically.
1. To create a care plan, log in to Barnestorm. Care Plans are available in both Barnestorm Office and Barnestorm Point-of-Care, and the functions are exactly the same in each.
2. To begin, select a patient by either searching the first or last name or chart number. You could also click My Patients or My Recent Visits.
3. Select a patient by clicking on the line that has his or her name and chart number.
4. The patient’s name will appear in the top window under Currently Selected Patient.
5. To open Care Plans in Barnestorm Office: click the Patient Histories button on the left menu bar. Select Care Plans from the options listed.
6. To open Care Plans in Barnestorm POC: click the Care Plans button on the left menu bar or from withing the assessment for a visit note.
7. The screen below will open; note the patient name and chart number at the top.
8. The first step for creating a care plan is entering a diagnosis. Do this by clicking the Add button which is right below Diagnoses at the top of the screen.
9. The screen for adding a new diagnosis will open.
10. If you know the code for the diagnosis, you may use the left pull-down, right beside of the word Diagnosis.
11. If you do not know the code, simply type the first word of the diagnosis, such as “Bowel” for “Bowel Incontinence.” A list of codes that begin with what you have typed will come up.
12. Select the diagnosis code that applies.
13. Below the code, you may change the Started date to indicate when the condition started, the employee, and the Status of the condition. Status values include: New, In Progress, Resolved, Unresolved, Stopped, and Scheduled. You change the status using the pull-down arrow on the right side of the field.
14. Type in symptoms and comments below the status, as needed.
15. Click the Save button in the lower right corner of the screen. The screen will go back to the main care plan screen, which will now have Outcomes and Interventions at the bottom. These outcomes and interventions are specific to the diagnosis selected on the top half of the screen.
16. Click one of the Outcomes in the lower left panel. Note that all of the buttons to the left become available.
17. Click the Assess button to assess that outcome. The Assessing Outcome screen will open.
18. At the top of the screen is the outcome, both with the code and the name to the right.
19. Below the outcome, you may change the Assessed date to indicate when the outcome was assessed, the employee, and the Status of the outcome. Status values include: New, In Progress, Resolved, Unresolved, Stopped, and Scheduled. You change the status using the pull-down arrow on the right side of the field.
20. If you would like to do so, you may use a Target Date by checking the Use Target Date box, and then select a date and enter a target value..
21. At the bottom is the value for the outcome. You may complete this value in one of two ways:
a. By typing a numeric value
Use this method if you have an internal system for defining values.
b. By using the indicators to calculate the assessed value
Use this method if you wish to have a standardized value calculation based on national standards. The scale used is 0 to 5, where 5 is best/healthiest and 0 is worst.
22. To use indicators to calculate the assessed value, click the pull-down arrow to the right of the indicator and a list of options will pop up immediately below the indicator. Select the option that matches the patient’s condition most closely.
23. Continue to indicate options on any indicator that applies to the patient. Note that each indicator will have options specific to its subject matter.
24. When you have completed the options, a numeric value will appear at the top of the Assessed Value section.
25. You have the option to use the average value of the indicators by checking the box to the right of the value. You also have the option to just type in a number rather than using the standard calculation (this is an agency-wide decision). If you wish to just type a number, remove the checkmark from the box.
26. When you complete the outcome assessment, click the Save button in the lower right.
27. Continue to assess outcomes until they are complete.
28. Next, you will use a similar process to assess interventions. Click an intervention in the list in the lower right section of the screen.
29. Click the Assess button to the left of the interventions. The edit interventions screen will open.
30. Below the intervention, you may change the Assessed date to indicate when the intervention was assessed, the employee, and the Status of the intervention. Status values include: New, In Progress, Resolved, Unresolved, Stopped, and Scheduled. You change the status using the pull-down arrow on the right side of the field.
31. You also have the option to enter a numeric value for effectiveness of the intervention.
32. At the bottom of the screen is the list of actions associated with the intervention. Simply click the checkbox beside each action that applies for this patient.
33. You may type in comments as needed.
34. Click the Save button in the lower right.
35. Continue to assess interventions until they are complete.
36. When a problem or outcome is resolved, you may click on it and then click the Resolve button to the left of it. That will mark it as resolved.
37. You may view the history for any problem, outcome, or intervention by clicking on it and then clicking the History button to the left of it. This will bring up a history screen for that item.
38. On the History screen, you may click on Edit to edit the assessment, or Delete to remove the assessment (do this carefully).
39. The lower portion of the History screen will show the assessed values over time.
40. To stop a problem, outcome, or intervention, click on it and then click the Stop button to the left of it.