The Care Documentation tab on the Client profile is where you can access information about the kind of care the Client should receive. It includes care-related planning and documentation (Care Plans, 485s, Attachments) as well as clinical data recorded during Visits (Medication Administrations, Vital Recordings, Wound Care Treatments, etc.)
Using the menu along the left in the Care Documentation tab, you can navigate to the following items:
- Medical History
- Care Plan
- Progress Notes
- Document Approval (for the 485)
- Wound Care
- Vitals and Vitals Configuration
- Client Attachments
Note that many of the Care Documentation modules are available on the mobile application as well as the web application.
The Medical History tab under Care Documentation is used to store information about a Client's Current Medical History, Past Medical History, Infectious Diseases, Past Surgeries and/or Treatments, Recent Hospitalizations, Immunization History, Allergies, and other relevant medical details.
The Client's Medical History will also appear under the Overview tab on mobile.
If your agency is required to submit a 485 for Clients, information in some sections of Medical History will automatically flow through to the form when a new 485 is created for the Client. For more details, see How do I complete a 485 in AlayaCare?
Progress Notes are one of many types of Notes available to document Client care. They can be added in the web app by Coordinators or the mobile app, by Care Workers.
If your agency is required to submit 485 forms for Clients, you can use the Document Approval tab to generate new 485s for the Client.
When you add a new 485, it will pull relevant details from the Demographic, Coordination, Medical History, Medication, Care Plan, Risk Assessment, and Equipment and Supplies sections of the Client profile.
After adding a new 485, the form will have a status of Draft. Once you have reviewed the Form, click Send. You will be prompted to add your electronic signature before marking it as Sent.
After the 485 has been approved and signed by the Client's physician, you can select Approve and upload the signed form to change the status to Approved.
You can also view 485s that have been generated, sent, rejected, or approved from Document Approval under the Overview tab on the mobile application.
InterRAI Assessments can be added for Clients from the Assessments tab in Care Documentation. Note that this feature is controlled by a Feature Flag.
Track and review a Client's Medication records: what they have taken, how, and when.
Document Infusion Sites and Infusion Maintenance for Clients requiring infusion therapy.
The Wound Care tab allows you to create Wound Profiles for Clients that have wounds that require clinical monitoring and treatment. Once you have added a Wound for the Client, care providers can add Treatments for the Wound during Visits.
You can add Wound Profiles and Wound Treatments on mobile as well as web.
- How do I add/edit a Wound for a Client on web?
- How do I add a Wound Treatment on web?
- How do I view/add/edit Wound Care - profiles or treatments (mobile)?
Vitals and Vitals Configuration
Care providers can use the Vitals tab to record a new Vital reading for a Client and review past readings for Vitals.
The Vitals Configuration tab can be used for choosing which Vitals you wish to make available for a Client and set minimum and maximum values as thresholds for different Vitals. You can also set up notifications so that an Event Task is created in the system whenever a value is recorded that crosses the set threshold.
Vitals can also be recorded for the Client on the mobile app.
- How do I configure Vitals on web?
- How do I record a Vital Reading on web?
- How do I generate notifications for Vitals (Event Tasks)?
- How do I review my Client's Vitals?
- How do I record a new Vital Reading on mobile?
Both back-office Employees and care providers in the field can use the Attachments tab for uploading important documents to the Client's profile. Select Upload file here to add a new document. Once you have uploaded the file, you can rename or copy the file. You can also create folders and move files between folders.
Attachments can also be accessed from the Attachments tab on Client's profile on the mobile application.