To outline expectations for a reassessment visit and ensure quality documentation of client needs and changes.
- 100% of client visits will be documented in the client EMR
- Reassessment visit is to be made any time there is a change in client’s condition or change in client’s needs and if client presents with symptoms or other issues that may be related to medications.
- May be completed at the client’s home or through use of telecommunication methods if this meets client’s needs. I
- If reassessment indicates a change in service type affecting the service fee than a service plan addendum must be completed.
- Reassessment visit it is scheduled in Clear Care on the client’s shift Calendar, assigned to the assigned RN Case Manager
- RCH - shift is scheduled as an hourly RN service, using the service: "Nursing Supervision"
- RCC - shift is scheduled as a visit, assigned to the appropriate RN Case Manager" using service, "Community Nurse 15 (or 30) Minute."
- "Documentation is done in the note section of the visit . To document note, RN must click on the assigned visit and select the note field. The Activity Tag must read, "Monitoring Visit: Reassessment" All charting can be entered here and should be completed in the home: