Client Reassessment

Purpose: 

To outline expectations for a reassessment visit and ensure quality documentation of client needs and changes.

Regulation: 144A.4791(8)(c)

Policy: 

Measurement:

1. 100% of client visits will be documented in the client EMR

Process:

1. 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. 
2. May be completed at the client’s home or through use of telecommunication methods if this meets client’s needs. I
3. If reassessment indicates a change in service type affecting the service fee than a service plan addendum must be completed. 
4. Reassessment visit it is scheduled in Clear Care  on the client’s shift Calendar, assigned to the assigned RN Case Manager
   1. RCH - shift is scheduled as an hourly RN service, using the service: "Nursing Supervision"
   2. RCC - shift is scheduled as a visit, assigned to the appropriate RN Case Manager" using service, "Community Nurse 15 (or 30) Minute." 
   3. "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: