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A Seamless Care Plan Process Using MDS 3.0, Diagnose, and Assessments

Using MDS 3.0, CAA’s, three pre-delivered care plan libraries, and correlations with User-Defined Assessments and diagnoses, NetSolutions Care Plan provides an intuitive and efficient method for building a resident’s individualized person-centric care plan as part of their EHR. The system also supports facility-defined care plan content to increase standardization and easily manage care plan conferences.

No More Starting from Scratch

With this NetSolutions application, you initiate a care plan by selecting from an online list of Suggested Problems. The problems are triggered by correlations between the NetSolutions MDS 3.0 Library and the resident’s MDS 3.0 responses, CAAs, diagnoses, and User-Defined Assessments (UDA).

Examples of triggered problems:

  • Fall Risk
  • Risk of Pressure Ulcer
  • Nursing History assessment

If you are already using a care plan library written by your facility staff, the software supports you in setting up correlations with that library to take advantage of the Suggested Problems feature.

As you select problems from the Suggested Problems list, you add goals and interventions from one or more libraries to build a care plan. Users can also choose to enter the care plan text into free-form fields or use a combination of methods. Document, report and re-new resolved problems with goals and interventions.

Individualized Care Plans

Build a care plan efficiently using the Summary panel that displays all current or resolved problems. It gives users tools clinicians need to select and deselect multiple items from multiple libraries as you choose the set of items for each resident.

Asterisks in Care Plan statements prompt for individualization, such as body part or left/right. Maintain the care plan with one online page that shows the complete care plan. Window can be collapsed or expanded. When users click on a problem, goal, or intervention, they can view and edit the text displays. The system tracks events in the software such as edits and views with user and date and supports storing a Care Plan Problem/Goal/Intervention as historical data prior to editing.

Care Plan Progress Notes

With Care Plan Progress Notes, you can:

  • Add free-form notes to a resident’s EHR to document progress related to a goal
  • Reference a care plan problem number for efficient retrieval and reference
  • Copy, edit and paste text from a previous note into a new one
  • Utilize Spell check function for accuracy
  • Print reports, problems and/or goals

Vitals for the EMR

Chart residents’ vital parameters and notes with this feature of NetSolutions Care Plan and Physician Orders. Data can flow to Vitals from CareConnection (RosieConnect) devices. The system maintains acceptable ranges and alerts staff when parameters fall outside of that range. Parameters include:

  • Blood glucose level
  • Weight
  • Temperature
  • Pulse
  • Blood pressure
  • Oxygen saturation
  • Level of consciousness
  • Respiration

Dashboard for Performance Indicators

The built-in NetSolutions Dashboard puts key performance indicators at your fingertips with drill-downs for details. Check the Dashboard for the number of New Admits, Readmissions, and Care Plan Goals Past Due and Care Plan Paused. Click for a list of those residents, along with actionable data.

MDS 3.0 Quik Plan Library

With the MDS 3.0 Quik Plan Library, you can build care plans by using pre-established statements as the foundation for individualized plans. The library offers complete problem complexes, formed by adding measurable goals and interventions to each problem statement. The MDS 3.0 Quik Plan library is included with the NetSolutions Care Plan system.

All problem complex statements can be customized easily to reflect facility-specific practices.

The MDS 3.0 library of Problem, Goal, and Intervention statements include correlations between problem statements and CAAs and MDS 3.0 items. Click the Suggested Problems link when you start the care plan for a list of the problems triggered. Select problems from the list and complete the care plan by selecting and individualizing statements of goals and interventions.

Edit the correlations between care plan problems and MDS items, diagnoses, CAAs, and User-Defined Assessment items built into the library to suit your facility’s standards. The library includes approximately 168 problems with accompanying goals and approaches. You can view and print the problem correlations in a master report.

Medical Diagnoses and I-PLAN Libraries

NetSolutions Care Plan includes a built-in Medical Diagnoses library. Browse the library of 60 diagnoses and select from the library of pre-defined goals and interventions that are available to add to the resident’s care plan. The Library Assistant feature prompts you to add language that individualizes each statement.

An optional I-PLAN library is available for use with NetSolutions Care Plan software at no additional charge. Based on nationally recognized standards of care, library items are written from the resident’s point of view with “I” statements. Statements can be individualized to match the resident’s ability and preferences.

As you complete a care plan, the software offers links to external Websites that provide additional care planning information and guidelines. Provides a link to standard care plan protocols and guidelines at the DHHS’ National Guideline Clearinghouse, a public resource for evidence-based clinical practice guidelines. NetSolutions supports setting up additional links.

Care Plan Conferences

Start by scheduling a Care Plan conference in advance including location and attendees in the Care Plan Conferences page, where you’ll see a summary of past conferences by date. Click the eAssign checkbox if your facility uses NetSolutions eAssignment & Messaging and has chosen that trigger. It will send a message to each attendee about the meeting. The system also supports paperless care plan conferences with tools for scheduling the conference, notifying attendees, signing in attendees, and entering notes.

When it’s time for the conference, attendees can sign in electronically. Facility staff simply enter their password and click Done. Attendees who aren’t in the system, such as family members, can sign in using a digital signature-capture pad. NetSolutions has been tested with the Topaz SigLite 1×5 pad model T-S460-HSB-R. After the conference, add notes on the Conference page.


Reporting Made Easy

Standard on-demand reports based on care plans include:

  • Nursing Kardex: A reference tool for direct-care providers, it clearly describes how much support a resident requires with Activities of Daily Living based on MDS responses that are imported automatically from NetSolutions MDS 3.0 software.
  • Care Plan: Complete text of the problem, goals, and interventions.
  • Care Plan Snapshot: Care Plan in effect on a certain date or date range for a resident
  • Documentation Records: Monthly schedules for each discipline to document care plan interventions. Create custom charting records for specific areas, such as a UTI record.
  • Acuity Report and Acuity Summary by client, by discipline

Additional Reports: Conference Report, Goals Due for Review, Goals Resolution, Problem Summary, Suggested Problems


Additional Features

  • Suggests problems based on correlations with the MDS 3.0 Quik Plan Library, CAAs, MDS 3.0 items, diagnoses, and items in User-Defined Assessments
  • Custom libraries may be exported to share with a sister facility.
  • Provides a Strengths window for adding positive resident information
  • Supports saving a partially completed care plan by using Pause and Resume buttons
  • Captures statements made by residents and family members
  • Updates review dates automatically following review date intervals (30, 60, 90 days) that you set up. The on-demand report lists goals due for review
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