Hospice Works: Nursing Visit Note & Audit Guard Co-Pilot Overview


Introduction

The Hospice Works Nursing Visit Note is a comprehensive documentation tool designed to streamline clinical reporting while ensuring regulatory compliance. The integrated Hospice Audit Guard Co-Pilot by HospiceWorks acts as a real-time clinical assistant, providing compliance scoring, documentation guidance, and AI-generated summaries to improve accuracy and efficiency.

Key Features

  • Automated Visit Linking: The system automatically recognizes and links notes to scheduled patient visits.
  • Dynamic Interventions: Sections marked "Intervention Required" (highlighted in red) ensure all mandatory clinical data is captured before a document can be signed.
  • Intelligent Assessment Logic: Selecting specific symptoms (e.g., anxiety) automatically triggers relevant sub-assessment panels (e.g., Mental Neurological).
  • Hospice Audit Guard Co-Pilot: An AI-driven sidebar providing:
  • Compliance Score: A 1–10 rating based on clinical documentation standards.
  • Guidance: Real-time analysis and recommendations for required corrections.
  • Draft Summary: An AI-generated clinical narrative based on visit data, saving up to 30 minutes per note.
  • Speech-to-Text: Integrated voice recognition for hands-free documentation in summary fields.


Workflow Guide

1. Visit Information & Vitals

  • Time Entry: Enter 'Time In' and 'Time Out'. The system prevents signing until all required fields are addressed.
  • Vital Signs: Enter current vitals. If a metric cannot be assessed, the system requires a specific reason (e.g., patient refused, patient sleeping).

2. Pain Assessment

  • Document whether the patient is comfortable.
  • If a pain level above zero is reported, the system prompts for additional details including location, frequency, and type of pain.

3. Clinical Assessments

  • Symptom Selection: Indicate if there are new or worsening symptoms.
  • Data Flow: The system displays previous assessment data (highlighted in blue) for easy comparison and updates.
  • Triggered Panels: Relevant sections (like Mental Neurological) will activate based on the symptoms selected to ensure thorough documentation.

4. Medication Management

  • PRN Medications: Document if "as needed" meds were administered. If not, a reason must be provided.
  • Reconciliation: Verify current medications, including Over-The-Counter (OTC) supplements.
  • Physician Orders: Use the integrated shortcut to add or update medications via the Physician Order link.

5. Patient & Family Education

  • Document the topics covered during the visit (e.g., disease process, medication instructions).
  • Confirm the caregiver’s understanding and the level of emotional support provided.

6. Care Plans & Next Visit

  • Care Plan Tracking: Update progress on specific goals (Improving, Stable, Worsening) and document interventions used.
  • Scheduling: Set the date and clinical focus (e.g., routine follow-up, wound care) for the next scheduled visit.

7. Documentation Summary & Reporting

  • Incident Reports: Prompts at the end of the note allow for the immediate creation of Patient Incident or Infection Reports.


AI Draft Summary:

  1. Open the Audit Guard Co-Pilot.
  2. Review the AI-generated narrative which includes clinical findings, visit context, and eligibility support.
  3. Edit or insert the summary directly into the Nursing Visit Note.


Final Review: Use the Speech-to-Text feature (blue microphone icon) to add any additional personalized observations.


Support & Resources

For further assistance or technical questions, please contact the support team:

  • Email: support@hospiceworks.com