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Opening a Visit

In order to write in a patient’s chart or to view any blank forms, orders, or care plan problems, you must first open a visit.  (NOTE: “visit” in HBC-lingo means that you are visiting a chart & wish to write in it)

• After you have selected a patient, the chart will open to the Overview Page. Click on OPEN VISIT in the Navigation Menu (bottom of the page) OR from the Patient Listing click on the Eye in the first column to Open the Visit
• Enter date and time.

Direct Care Visit

If recording a direct care visit with a patient, enter the arrival date and time that you were with the patient. 

NOTE: IT IS EXTREMELY IMPORTANT THAT DIRECT CARE VISITS ACCURATELY REFLECT TIME SPENT WITH THE PATIENT.

Phone Call Visit

If recording a phone call, preparing for IDG/IDT, recording receipt of physician signatures on orders you can leave the default date/time (which is “real” time)

IPU or Continuous Care Visit

If working in an IPU or performing Continuous Care, you would enter date/time that your shift started.

Enter a Visit Type

If recording a contact with a patient, make sure to choose the most appropriate direct-care visit type.  The visit type should also match the patient’s level of care. (i.e. if patient is general inpatient, the corresponding visit type should be used if your agency’s visit types are set this way)

A list of forms will appear. The forms displayed are mapped to your job description and to the Visit Type that you chose.

If you do not see the FORM you want to fill out, you may click “ALL FORMS” in the task bar and see all available forms.

If the visit type you need is still not listed, report a problem to tech support. If recording a phone call, there should be a “phone call” visit type; if recording documentation for IDG/IDT, there is an “IDG/IDT Visit Type,” etc.

• Note that direct care visits for nurses, social workers and CNA/HHAs transfer over to the claim form for Medicare. Thus, it is imperative that the correct visit type is used.
• Click “Open” in top right-hand corner (you will know that the visit is open by seeing Visit Open (#__) at the bottom of the screen).

Closing the Visit

In order for the information that you have written in the patient’s chart to be available to your team members, you have to close your visit.  The act of closing the visit sends the information back to the server if you are working on-line.  NOTE:  If you are working off-line, you must ALSO synchronize your visit after closing.

• You must complete all required fields of the forms, care plans, medications and orders that you have opened in order to close a visit. (NOTE: if you open a form, care plan or order by mistake, click on UNDO in the Task Bar)
• If you have opened this visit by mistake or decided that no documentation was necessary, you can click on Undo Visit in the bottom Navigation Menu.
• To close, click on Close Visit in Navigation Menu.
• Confirm the date and times for the visit are correct.
  • If documenting a direct care visit with a patient, enter the date and time that you were with the patient. IT IS EXTREMELY IMPORTANT THAT DIRECT CARE VISITS ACCURATELY REFLECT TIME SPENT WITH THE PATIENT
  • If recording a phone call, preparing for IDT, recording receipt of physician signatures on orders you can leave the default date/time (which is “real” time)
  • If working in an IPU or performing Continuous Care, you would enter date/time that your shift ended.
  • Note whether team has been notified or not.
• Click on “Close” in top right-hand corner.