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WHO SHOULD READ THIS DOCUMENT? <returntomenu>menu ↑<returntomenu>

This document is intended only for Careficient Administrators who are responsible for creating agency-wide forms within Careficient. It is not intended for agency use.

UNDERSTANDING SERVICE NOTES (FORMS) <returntomenu>menu ↑<returntomenu>

Careficient provides a standard set of assessment and service note formats, known as Service Note Types, which comply with health care industry standards. It offers tools to update service note information to meet your agency’s requirements.  


Patient services in home health are typically delivered in a residential or home setting rather than in a medical facility. As the use of technology in home care has increased, more clinicians are utilizing Point of Care applications to document assessment and service note information at the patient bedside.

Point of Care technology streamlines the review and approval process for physician orders, OASIS assessments, and service notes and eliminates the need to review paper documents. This greatly speeds up the document processing cycle. The inclusion of Point of Care technology in home health has automated the flow of patient information into agency records without the need to rekey.  Careficient provides a standard set of assessment and service note formats, known as Service Note

Types, which comply with home health industry standards. Occasionally, you may need to make changes to these forms or add new forms to comply with your organization’s internal policies and procedures. Careficient provides you with the tools to update service note information to meet your custom requirements.  

GENERAL NAVIGATION AND LAYOUT OF SERVICE NOTES <returntomenu>menu ↑<returntomenu>

Each service note has a time slip at the top it. The patient assessment and service note information are just below. Service notes are divided into sections and can be associated with an OASIS system.

Careficient uses several software conventions, including:

You can make the following changes to service notes in Careficient:

SERVICE NOTE TYPES <returntomenu>menu ↑<returntomenu>

Careficient is a management tool that lets home health and private duty providers accept referrals, admit patients, schedule and verify services, create all clinical documentation, pay associates, and bill and collect for services. When providing a service, Service Note Types let you identify the form you want to use to collect data.

Service Note types may include:

As part of the clinical documentation, Careficient lets you easily define, manage, and customize service note forms. You can integrate existing data from service notes and OASIS forms into your agency’s online forms.  

OASIS INTEGRATION <returntomenu>menu ↑<returntomenu>

OASIS (Outcome and Assessment Information Set) is an important part of the Centers for Medicare and Medicaid (CMS) partnership with the home care industry. The electronic OASIS form is used to collect and report performance data by home health agencies. CMS requires Medicare-certified home health agencies to collect and transmit OASIS data for all adult patients whose care is reimbursed by Medicare and Medicaid payers, including Medicare Advantage plans and Medicaid

home health programs.

To that end, Careficient lets you integrate service notes for use on the OASIS form. You can then complete the required OASIS information and electronically submit the data to the CMS OASIS contractor through Careficient. You can even display information that is not required by OASIS as an integrated part of the OASIS form.

Using agency-specific forms, Careficient also lets you integrate custom elements into an OASIS form. Although the official OASIS form does not change, you can use Careficient Form Builder to attach custom sections to it.  

DATA COLLECTION OASIS TIME POINTS <returntomenu>menu ↑<returntomenu>

An OASIS time point is the stage (or point) in the patient care cycle when OASIS data is collected. Each time point has specific information (or data sets) associated with it. At each OASIS time point, a precise data set is required.  

When you build a form in Careficient, you can specify an OASIS time point and include this required data on your customized form. In order for any form to be OASIS-integrated, you must assign it a time point.

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