Resident Care Management: Medical Info, Notes &

LOA Tabs

This session includes Resident Care Management entry of Medical Information, Notes and LOA tabs. The Medical

Information tab is where you enter Evacuation Status, Diet, Allergies, Orders, Code Status, Advanced Directives, Durable

Medical Equipment, Notes/Alerts and TB Status.

Medical Info Tab:

Note: The other tabs shown in this print screen may be different in your database than the tabs displayed. The tabs

shown are based on modules used and employee access granted.

Evacuation Status and Diet:

Click on the lookup to select the resident’s Evacuation Status and Diet. If there is nothing in the master list, you will be

prompted to create the list. You will also be able to edit current choices or add new ones from the lookup as long as you

have been given access to modify choice lists in the employee setup.

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Diet:

Diet is a multiple select lookup. Click on one diet or as many as you need for this resident, and then click on ‘Select’.

Allergies:

To add an allergy to the

resident, click on the

green add button.

A list of allergies will be

displayed.

You can type in the “Filter By” field to shorten the list or use the

scroll bar to find the allergy you need.

If the allergy you are looking for is not on the list, click on the

“Modify” button to add.

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Orders:

Code Status/Advanced Directives:

Code Status and Advanced Directives check box options must be set up in the master. The items you see in this

manual may not match your screen.

Durable Medical Equipment:

Click the Add button. Enter the start date. The note field is used to describe the equipment. You may want to include a

serial number or some other identification number. Examples of items that would be entered: Wheelchair, Walker or

CPAP machine.

Click on the add button. Enter a start date in the

Start column. Enter the order text into the

Description field.

Note: Due to the type of list used for orders, the

standard date entry shortcuts do not function. You

will need to add the date as MM/DD/YY.

When an order ends, enter the end date.

Note: All new residents default to a code status of resuscitate or the top

choice under code status if the name has been changed in your

database. In the example shown it is ‘Full Code’.

If a resident changes from a ‘Full Code’ to a ‘No Code’, you will need to

remove the checkmark from ‘Full Code’ and click the check box for ‘No

Code’.

The text field below advanced directives can by used for any additional

notes about code status or advanced directives.

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Note/Alert:

Click the Add button. Enter the start date. Enter the note or alert in the note field. Examples of items that could be

entered: Fall Risk or Hospice.

TB Status:

Click the Add button. Select the TB test type. Note: If no ‘TB Test Types’ have been added, you will be prompted to setup

the list.

Enter the test date and press the tab key, the choices for ‘TB Test Result’ will open. Note: If no results have been setup

you will be prompted to setup the list.

Highlight the test type and click select, or double click

the test type to select.

If you are not ready to record the results, click on

cancel.

If you are ready to record the results, highlight the

result and click select, or double click the test result to

select.

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Notes Tab:

Notes can be used to enter progress notes and other types of narrative documentation. If you do not have the Risk

Management Module turned on for your facility, you will also be able to enter accident or incident reports.

NOTE: The incident and accident reports contain limited fields. More in-depth forms are located in Risk Management. If

your facility is interested in using Risk Management, please contact Eldermark Support.

Note entry screen:

Click Add to enter a new progress note.

Double click a line to review a note.

Note: Editing permissions are set up in

the company settings.

Depending on how your facility is set

up, you may or may not be able to edit

a note once it is saved.

Note Type: Click the lookup to select.

Type your note in the note field and click

save.

Spell check will run if you have misspelled

words.

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Printing Progress Notes:

You can print the note you entered from the printer button at the bottom of the window. If you want to print a group of

Progress notes for a resident, you do this from the Note listing screen.

Click the Print button.

Notes Print Criteria Window:

You can also access or print from File – Notes. It is possible to view notes for all residents in this area.

The default setting is to print any notes that have not

been previously printed through the current date.

If you want to reprint notes, remove the checkmark

from “Since Last Printed” and enter the date range

desired.

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LOA Tab:

This where you record the resident’s time out of the facility on a leave of absence. Click on the add button to

enter a new leave. The following window will open:

Click on the calendar next to the ‘From Date’ to select the date, or enter the date into the field. Enter the time the

resident left on the leave.

If this is a leave that you know when the resident will be returning, you can enter the ‘To Date’ and time. Note:

The information can be edited if the resident does not return on the date or at the time entered.

Select the ‘Reason’ why the resident went on the leave of abscence (out to the hospital, on vacation with family, etc.),

and enter ‘Who Requested’ the leave.

‘Resident on Leave’,’ All Services on Hold’ and ‘All Meds on Hold’ default to being checked.

Once all information is correct click on the Save button.

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All planned services will no longer appear on the next Daily Service Schedules created or re-created. Service on Hold

from Date will display on the Services screen. If an end date is also entered that will display as well.

When the resident returns services need to be reinstated. Double click on the resident name from the resident list to

open the record. Click on the LOA tab and enter the correct ‘To Date’ and ‘Time’. Click ‘Save’. The ‘Daily Service

Schedules’ created or re-created after the LOA record is updated will show this resident’s services again.

NOTE: To place one or some of a resident's services on hold go to the Services tab within Resident Care Management

and mark individual services on hold as needed.

Areas in Service Minder that use the LOA records:

Resident On leave: when a resident is on leave over midnight the Census report will not include them in the 'head

count'. The Resident Roster will show them as out and include the Reason from the Service on hold/LOA record

All Services on Hold: When creating schedules all services for this resident will stop scheduling during the duration of

the record. Services on Hold is also used by Billing Transaction Types that are set to prorate by Service on Hold.

All Meds on Hold: Medications will be put on hold. If the resident has medications marked on hold when the medication

sheet is printed, an H for hold will print in the passing times for each medication.

Note: If your facility uses EMAR, there will be an additional option to mark: ‘Pre-Pour & Send Meds’. Details on this can

be found in the EMAR Manual.

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LOA records can also be accessed from the file menu. Click on File – Resident on LOA and the following screen will open:

This listing shows all resident’s LOA records. You can review current residents on LOA by clicking on Hide Closed Items.