Add Your Worksheets to the EMR and Export Data to MDS 3.0
User-Defined Assessments eliminates paper assessments and puts the information in residents’ Electronic Health Records. It increases efficiency by exporting data to MDS 3.0 items and to the Care Plan Suggested Problems list. More than 100 assessment templates are available to download, modify, and use free of charge.
Let the Software do the Heavy Lifting
With NetSolutions User-Defined Assessments (UDA), users enter assessment responses online and stand back while it:
- Calculates scores
- Maintains histories
- Notifies staff of assessed responses not limited to Deep Tissue Injuries, Fall Risk using NetSolutions eAssignments
UDA lives up to its name – user-defined – by offering unlimited flexibility for capturing exactly the information you want in worksheets and assessments, such as level-of-care evaluations, condition changes, and pre-admission worksheets.
UDA’s user-friendly interface allows users to complete a form in any order. Learning curves are short since the look and logic of UDA are the same as NetSolutions’ MDS 3.0 software.
UDA gives you a choice of creating your own assessments or using pre-built templates of assessments. Your software arrives with 27 templates loaded, with many more available to download.
Share Responses with MDS 3.0 and Care Plan
The Nursing History & Assessment template is pre-loaded in UDA and comes with pre-built MDS 3.0 correlations. It was designed to be an online version of a typical head-to-toe assessment that facilities use at admission, between MDS assessments, and annually. Compare results over time with a History report.
To increase efficiency, items included in the UDA Nursing Assessment that match MDS 3.0 items are already linked. The UDA data is automatically available to import as you complete an MDS 3.0 assessment. Simply click the Import button to select UDA responses to import.
Correlations with Suggested Problems
Users can set up correlations between UDA assessments and the list of Suggested Problems that is used to develop Care Plans. Correlations would be in addition to the set of correlations built into the system.
This software provides users with tools to link responses from one UDA assessment to another. For example, you could set up a correlation between the choice “Mild” in “Muscles of Facial Expression” in the AIMS to the choice “Mild” in the Grimaces section of the DISCUS.
NetSolutions clients and staff can share additional templates they’ve created with other facilities by posting them on our clients-only website.
Implement Your Own Assessments
When designing an assessment, users enter the questions and how they want them answered: with yes/no, multiple-choice, or text. Add correlations to export data between UDA forms and MDS 3.0 items, and between UDA forms and Care Plan Suggested Problems.
Attach score values to each response upon assessment setup and UDA calculates total scores. Skip scoring if not appropriate. UDA can be set up to compare scores and report changes as increased, decreased, or unchanged. “Required” questions can be specified. An audit will show any missing required fields.
Instructions for conducting an assessment can be added so they are readily available online. An example from the AIMS:
“4. Have the resident sit in chair with hands on knees…”
Users can add their facility’s policies and procedures on a form or template to support standardization.
Reporting: Ad Hoc and On-Demand
With Ad Hoc reporting, users can combine data from MDS 3.0, ADT/Prospects, and User-Defined Assessments (UDA) to create specific reports, such as all residents in a certain station, who are patients of Dr. Smith, and use a hearing aid. Pulls data in ADT to UDA assessments including census information, Advance Directives, diagnoses, allergies, and contact information.
On-demand reports can be generated by one, some, or all residents and include History, Due Dates, and Resident Comparison.
Medicare Certifications and Recertifications
Templates for Medicare Certifications and Recertifications are included and can be signed electronically by physicians with system access. They can also be printed for a paper process and formatted as a PDF for emailing.
Recording Statements from Residents and Family
NetSolutions can capture statements made by residents and family members in a window that pops up on top of the page where you’re working. To add a comment, simply enter its text, add the type of note, and assign it to a folder.
Enter assessment information for prospective residents before they register to make sure their needs match your facility’s resources. At registration, the assessment becomes part of their EHR. Retains assessment data for prospects.
Add Value to Assessments with Notes and Correlations
Free-form notes can be added to an assessment. The Trends window displays a history of assessments with scores and a graph to identify improvement or decline in a resident’s condition. Responses from one assessment can be linked to another, creating a flow of data.
You can set up correlations with MDS 3.0 items and with items in the Suggested Problems list in Care Plan.
Pre-loaded Assessment Templates
NetSolutions UDA arrives with the following 27 assessment templates already loaded. You can use a template as is or modify it. Additional templates (100) that were created and shared by our staff and clients are available to download from the clients-only section of our website.
Abnormal Involuntary Movement Scale (AIMS)
The Abnormal Involuntary Movement Scale (AIMS) assessment measures a resident’s current neurological condition based on observable involuntary movements and indicates whether the resident should be referred for a full neurological examination. It contains twelve response items under five headings. The instructions include a scale for interpretation of the AIMS score.
ADL Decline Assessment
The Activities of Daily Living (ADL) Decline Assessment records a resident’s level of physical and mental activity and helps track changes that may be a cause for concern. It includes sixteen response items under five headings. A scoring system can be added during the facility setup. This assessment can provide some of the required documentation for the ADL CAA and the Physical Functioning ADL Quality Indicator.
Bedfast Resident Assessment
The Bedfast Resident Assessment uses a subset of the ADL Decline Assessment to evaluate the causes and consequences of bedfast in a resident. It contains thirteen unscored response items in three categories. This assessment can provide some of the required documentation for the Pressure Ulcer Quality Indicator and the Bedfast Quality Indicator.
Bowel and Bladder Evaluation
The Bowel and Bladder Evaluation assesses factors contributing to incontinence in a resident and tracks interventions taken to resolve or manage the condition. It contains 22 response items under seven headings. Option to add a scoring system is available.
Comprehensive Skin Assessment
This assessment provides an in-depth assessment of a resident’s:
- skin problems and history
- nutritional and hydration status
- preventive measures for skin conditions
The Dehydration Review helps analyze the causes, symptoms, and complications of a resident’s dehydration. It has 30 response items under seven headings with the ability to add scores. This review can provide some of the required documentation for the Dehydration CAA, the Dehydration Quality Indicator, and the Surveyor Investigative Protocol for Hydration.
Diminished Activity Assessment
The Diminished Activity Assessment helps evaluate a resident who has poor activity attendance. The emphasis is on the relation between cognitive functioning and social participation. Scores can be added to the sixteen response items. This assessment can provide some of the required documentation for the Activities CAA and the Activities Quality Indicator.
Discharge Instructions For Care
The Discharge Instructions for Care form provides a structured document for residents and their next of kin to receive care instructions at discharge. It includes sections on medications, wound care and treatment, diet, the resident’s physical status, resources and services for the discharged resident and important contact numbers, and follow-up care instructions.
Discharge Plan/Discharge Plan Review
The Discharge Plan/Discharge Plan Review document establishes the plan for a resident’s discharge. It provides a comprehensive review of the resident’s status on admission followed by sections for the physician’s input regarding the discharge, the resident’s and resident representatives’ reaction to the discharge plan, community, and referral resources for the discharged resident, and comments.
Discharge Summary and Interdisciplinary Recapitulation of Resident’s Stay
This assessment provides a summary of the resident’s stay and status at discharge as evaluated by multiple disciplines. After a summary of the resident’s stay and the reason for discharge, it includes sections for entering a Social Services summary, resident belongings notes, most recent vital signs and labs, and a detailed Physical Function summary. It also documents the resident’s assistive devices, special treatments, dental status, allergies, nutrition guidelines, activities and restorative programs, and post-discharge plan.
Dyskinesia Identification Scale—Condensed User Scale (DISCUS)
The Dyskinesia Identification System – Condensed User Scale (DISCUS) assessment measures the neurological side effects of psychotropic medications. It includes both the main DISCUS neurological exam and an Evaluation section documenting other factors. This is a scored assessment with detailed instructions for diagnosis.
Faber Fall Risk Assessment
The Faber Fall Risk Assessment evaluates a resident’s level of risk for falls. It includes 29 response items under headings such as Disease or Condition, Physical Functioning, and medications. Scores can be added. This assessment can provide some of the required documentation for the Fall CAA and the Fall Quality Indicator.
Faber Pressure Area Risk Assessment
The Faber Pressure Area Risk Assessment helps identify a resident’s risk for pressure ulcer development. It contains 26 unscored Yes/No response items. This assessment can provide some of the required documentation for the Pressure Ulcer CAA, the Pressure Ulcer Quality Indicator, and the Surveyor Investigative Protocol for Pressure Sores.
The Impaction Assessment provides a set of questions to evaluate causes of fecal impaction in a resident and to record actions taken to resolve the problem. Contains eight unscored Yes/No items. This form can provide some of the required documentation for the Impaction Quality Indicator.
Interdisciplinary Discharge Summary
The Interdisciplinary Discharge Summary provides a recapitulation of the resident’s stay and status at discharge for interdisciplinary care providers, including Social Services, Nursing Services, Dietary Services, Activities, and Rehab Services, plus a Comments/Additional Note section for each discipline.
Interdisciplinary Foley Catheter Assessment
The Interdisciplinary Foley Catheter Assessment records the care team’s rationale and recommendations regarding a resident’s need for a Foley catheter. Contains four unscored text entry response items. This assessment can provide some of the required documentation for the Urinary Incontinence/Indwelling Catheter CAA, the Presence of Indwelling Catheter Quality Indicator, and the Urinary Tract Infections Quality Indicator.
Interdisciplinary Restraint Assessment
The Interdisciplinary Restraint Assessment records the care team’s rationale and recommendations regarding restraint use on a resident. Contains 40 unscored response items under seven headings. This assessment can provide some of the required documentation for the Physical Restraint CAA and the Restraint Quality Indicator.
Interdisciplinary Weight Loss Risk Assessment
The Interdisciplinary Weight Loss Risk Assessment helps nurses and dietitians determine the cause of a resident’s weight loss. Includes 29 unscored response items in three categories. This assessment can provide some of the required documentation for the Nutritional Status CAA, the Weight Loss Quality Indicator, and the Unintended Weight Loss Surveyor Investigative Protocol.
The Maryland MDS template enables you to conduct the MMDS state assessment for your residents on the Assessments page. Once you have conducted an assessment, you can print the MMDS as a NetSolutions user report. First, add the report on the User Reports Setup page, then print the report from the User Reports page. Both pages are accessed from the Reports tab task menu.
Medicare Certification and Recertification templates
With this set of six templates, you can complete the Medicare certification process for residents within their EHR. It includes the following templates:
- Medicare Initial Certification and Recertification
- Medicare Recertification of continued SNF inpatient care. On or before the 14th day of admission.
- Medicare 2nd Recertification 30DAY
- Medicare 3rd Recertification 60DAY
- Medicare 4th Recertification 90DAY
- Medicare 5th Recertification 120DAY
Nursing History and Assessment
The Nursing History and Assessment is intended as a general assessment for nurses to conduct with a resident on initial entry to a facility or on a periodic basis such as quarterly or annually. The assessment consists of 18 sections covering standard areas of concern for long-term care residents including Allergies, Vital Signs, Diagnoses, Immunization History, Cognitive Status, and more.
This template is set up with correlations to the MDS 3.0. When you conduct a UDA assessment that is correlated to the MDS, the responses to the correlated items are made available the next time you conduct the MDS 3.0 assessment. In each section of the MDS, you can click the Import link to import the correlated data that was entered in UDA.
Quality Assurance Dining Observation
The Quality Assurance Dining Observation aids dieticians in evaluating the dining room. It contains twelve unscored response items under two headings. This form can provide some of the required documentation for the Nutritional Status CAA, the Weight Loss Quality Indicator, and the Dining and Food Service Surveyor Investigative Protocol.
Quality Assurance Random Hydration Review
The Quality Assurance Random Hydration Review helps determine the hydration needs of a resident. Contains eight Yes/No questions, unscored. This form can provide some of the required documentation for the Dehydration CAA, the Dehydration Quality Indicator, and the Food Service Surveyor Investigative Protocol for Hydration.
Resident Interview for Dietary
The Resident Interview for Dietary form assists Quality Assurance in identifying problems in meal consumption and meal delivery. Contains ten Yes/No questions, unscored. This form can provide some of the required documentation for the Nutritional Status CAA, the Weight Loss Quality Indicator, and the Food Service Surveyor Investigative Protocol.
Residents Who Have Cognitive Deterioration
The Residents Who Have Cognitive Deterioration assessment provides for detailed documentation of any changes in a resident’s level of cognitive functioning. It contains 29 unscored Yes/No questions under five headings. This form can provide some of the required documentation for the Cognitive Loss CAA and the Cognitive Quality Indicator.
ROM Decline Assessment
The Range of Motion (ROM) Decline Assessment evaluates the causes and complications of range of motion reduction in a resident and tracks any restorative or maintenance measures taken. Includes sixteen response items in five categories. This assessment can provide some of the required documentation for the Decline in Range of Motion Quality Indicator.
Assessment Templates Available to Download
- 72-Hour Post Fall Observation and Assessment
- Activities Assessment
- Activities Comprehensive
- Activities Evaluation
- Activities ReAssessment
- Activity Annual and Quarterly Assessment
- Admission & Annual Nutrition Assessment
- Admission Data Collection
- Anti-Anxiety Assessment Tool
- Anti-Depressant Assessment Tool
- Anti-Psychotic Assessment Tool
- Bed Safety Assessment
- Braden Scale (3 versions)
- Brief Cognitive Rating Scale (BCRS)
- Cardiac Pacemaker Information
- Care Plan Conference Summary (2 Versions)
- Change In Condition
- Clinic Service Assessment
- Clinical MDS Review Assessment
- Community Applicant Profile Questionnaire
- Comprehensive Hydration Risk Evaluation
- Consultant Dietitian Eval
- Contracture Tracking
- Daily Licensed Nurses Notes
- Daily Medicare Charting
- Daily Skilled Nurses Notes
- Dietary Meal Card
- Early Detection of TB Questionnaire
- Elopement Risk Assessment
- Evaluation for Bowel and Bladder Training
- Existing Pressure Ulcer List
- Fall Incident COC Assessment
- Folstein Mini-Mental Status Exam
- Geriatric Depression Scale
- Hydration Risk Form
- Initial Restraint Assessment
- Impact of Events Scale
- IPA Weekly Review
- Life Enrichment Assessment
- Mattress Assessment
- Medical Nutrition (Initial) Therapy Assessment
- Nurses Weekly Summary
- Nursing Communication to Therapy
- Nutrition Screening
- Nutritional Risk Screening
- Pain Assessment
- Pain Assessment Tool
- Pain Data Collection Tool
- Patient Health Questionnaire (PHQ-9)
- Physicians History and Physical
- Post Hospital Return Assessment
- Pre-Certification for SNF Stay
- Pre-Admission Assessment
- Pre-Admission Nursing Assessment
- Pressure Area Risk Scale
- Pressure Ulcer – Initial Weekly
- Psycho-Social Assessment
- Psychotropic Review
- PTSD Scale
- Quarterly Medical Nutrition Therapy Assessment
- Registered Dietitian Nutrition Assessment
- Resident Activity Interest Assessment
- Resident Care Card
- Resident Transfer Guide
- Resident/Family Education Record
- Respiratory Assessment
- RN Assessment Tool
- SBAR (with and without Progress Notes)
- Sedative Hypnotic Assessment Tool
- Self-Administration of Medication Assessment
- Service Plan
- Side Rail Evaluation
- Skilled Documentation Flow Sheet
- Skin Assessment/Review
- Smoking Assessment Tool
- SNF Coumadin Flow Record
- Social Service Anticipated Discharge Plan
- Social Service Assessment
- Social Service Discharge Referral
- Social Services Initial Assessment
- Social Services Resident Weekly Summary
- Suicide Risk Assessment
- Suicide Risk Assessment – RAG
- Tenant Summary Assessment
- Thirty (30) Day Restraint Review
- Urinary Catheter Assessment
- Utilization Review – Rehabilitation to Home
And many more…