When an episode is started by the nurse (Oasis SOC) and PT comes in, the nurse discharges with a SN discharge as patient met goals, PT remains in and recerts the patient, the new plan of care still has the nursing goals in it as the SN discharge does clear out the goals that have been met. The QA nurse has to edit the new plan and remove the nursing goals that have been met. We were told only a OASIS D1 discharge would clear out the goal. Obviously, we are still providing PT for the patient so and Oasis D1 discharge can not be preformed by the nurse. Pt will do the Oasis D1 discharge when complete. This is very time consuming having to edit the new plan of care. Does anyone have a work around as AXXESS is clueless. Help. Thanks
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Good morning Samuel,
Thank you for using the Axxess User Community!
If one discipline is discharging and another continuing, I would suggest that you use a regular discharge visit (in your example this would be a SN D/C) and complete a discipline discharge summary by either scheduling this task or generating a intra episode/ discharge episode summary under the quick reports of the patients chart. The SN D/C visit looks like a regular visit and the clinician can access the plan of care profile within it. Within the plan of care profile the clinician can resolve all nursing goals.
The OASIS D1 is not the only way to resolve goals in the patients chart. This can be done from any subsequent note or orders. Clinicians should be resolving goals throughout the episode as they are met. We apologize for any previous misunderstanding and inconvenience this may have caused. As always we value your feedback.
Your friend at Axxess,
Tiffany
my situation was referencing a sn discharge non visit because the patient was unable to be seen
Hello again Samuel,
The only default discharge visit that is non billable is an OASIS unless your agency created a custom note. You could if you wanted take a regular skilled nursing note, create a custom note (this is permission based) titled Non billable SN discipline Discharge you could do that and then mark the visit as non-billable in the task’s details section. If your agency was just doing a discharge summary the other option would be to write a physicians order and select “Plan of Care Order”. You can discontinue orders and resolve goals from there. If the order does not need a physicians signature you may select “No physicians signature Required/ Do not Send”. That feature again is permission based.
Hope this was helpful,
Your friend at Axxess,
Tiffany