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HOME HEALTH
CLINICIAN TRAINING
MANUAL
July 2021
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Table of Contents
LOGGING IN ........................................................................................................ 4
AXXESS PLANNER.............................................................................................. 5
DASHBOARD ....................................................................................................... 7
My Schedule Tasks ........................................................................................... 8
EDIT PROFILE ................................................................................................... 10
RESET SIGNATURE .......................................................................................... 11
MY MONTHLY CALENDAR ............................................................................... 11
PATIENT CHARTS ............................................................................................. 12
VISIT DETAILS ................................................................................................... 13
QUICK LINKS ..................................................................................................... 14
Allergy Profile .................................................................................................. 14
Medication Profile ............................................................................................ 15
Immunization Profile ........................................................................................ 17
Infectious Disease Profile ................................................................................ 18
Preadmission Notes ........................................................................................ 19
Communication Notes ..................................................................................... 20
Orders and Care Plans .................................................................................... 20
Plan of Care Summary .................................................................................... 21
Vital Sign Charts .............................................................................................. 21
Authorizations Listing ...................................................................................... 22
Episode Summaries ........................................................................................ 22
Triage Classification ........................................................................................ 23
Deleted Tasks/Documents............................................................................... 23
PATIENT CHART TABS ..................................................................................... 23
New - Order ..................................................................................................... 23
New - Aide Care Plan ...................................................................................... 25
New - Communication Note ............................................................................. 25
PDGM Dashboard ........................................................................................... 26
Documents ...................................................................................................... 28
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SCHEDULE ACTIVITY ....................................................................................... 29

SCHEDULING A VISIT (PERMISSIONS BASED) .............................................. 30
DELETING A VISIT (PERMISSIONS BASED): .................................................. 31
OASIS-D1 START OF CARE: ............................................................................ 32
HELP CENTER ................................................................................................... 35
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LOGGING IN
Go to www.axxess.com, and select LOGIN, located in the upper right-hand
corner.

Enter the username and password then select Secure Login.

The username is the email address assigned to the user’s account when it was
created. The password was created by the user, from a link that was sent to this
email address. This password will also be the user’s electronic signature. If the
user forgets their password, select Forgot your Password? and a link will be
sent to this email address. Here, the user can reset their password, however the
electronic signature will remain the same. After the correct username and
password are entered, the following message will display:

Select OK and the user will see the Axxess Planner.

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AXXESS PLANNER

• Date/Time/Weather – Today’s date, time and five-day weather forecast for

the user’s specific area.
• Today’s Visits Schedule – Select the icon for a calendar view that
shows the user’s visit schedule (with red dots marking the dates the user
has visits).
o Selecting the day will bring up the tasks schedule. Selecting the
task will show the status of the visit. The visit can be started from
here by selecting the START icon. Select the patient’s name to go
directly to their chart.
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• Today’s Visits Map – View directions for user’s daily visits or plan out their
route.
Green – Current Location
Red – Visit Location
Blue – Selected Visit

Select the marker to view the details of the visit.

Select Get Directions and this will take the user to Google Maps, giving turn-by-
turn directions and a visual map.

• Unread Messages – This is a list of unread messages from the Internal

Messaging Center. Selecting a message will take the user directly to the
Messaging Center.
• Past Due Visits – This is a list of visits from the last 21 days that have not
been completed and signed.
o Selecting the red Open tab on the left-hand side of the visit will
show the note and allow users to view the chart. The visits list from
oldest to newest. However, they can also be sorted to reverse the
order from newest to oldest.
• Alerts – A list of all visits/tasks that have been returned to the user from
the QA Center.
o Hover over the red sticky note to view comments from QA.
o Select the orange Open tab to chart on the note/visit.
o Inside the note, a message will be displayed in red font that the
document has been returned by QA. Select View Comments to
read the message and send back any response.
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On the left-hand side of the screen is a list of organizations that the user works
with, as well all the products to which their organization is subscribed.

DASHBOARD
The Dashboard opens upon login. Five tiles will appear, but four more may
appear based on permission settings for the roles/duties in the organization (see
Admin Overview). Below are the five default tiles for all clinicians:
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1. Welcome Panel – This includes items for subscribers to Axxess solutions,

with interactive announcements and helpful training videos.
2. Recertifications Due – Shows graphically how many recertifications are
Past Due in the red circle and the number of Upcoming in the blue circle.
3. Unread Messages – This is the HIPAA-compliant email messaging
center, allowing all organization users to communicate securely. When the
user receives messages, notifications will be sent to the user’s email
assigned to their account.
4. News & Updates – This shows links to Axxess-generated blog posts,
educational articles, regulatory updates and other important information.
5. Patient Birthdays – Lists the name of upcoming patients along with their
birth date, age and phone number.
6. My Schedule Tasks – This panel is your electronic “To-Do” list. Users can
quickly access a patient chart and/or tasks for the first five patients on
their to-do list.

My Schedule Tasks
Select the View All Tasks hyperlink in the bottom left-hand corner of the tile to
view the entire list of scheduled tasks.
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• Notice this list will only go three months into the past and two weeks into
the future. For older items, view the Schedule Center or the Patient’s
Chart.
• You can also export this data into an Excel with the Excel Export button.
There are three ways to group data: Patient Name, Date and Task.

Sticky Notes:
Red – Missed/Return reason from either QA Center or another clinician.
Yellow – A note pertaining specifically to this visit that communicates to other
users.
Blue – A note that has information for every visit in an episode (ex. A gate
code or where to park). This information will appear in a sticky note on every visit
in that episode.

Missed Visit Form - When a visit is missed for any reason, select the Missed
Visit Form hyperlink. A window will pop up, asking for a reason, comments, the
Staff Signature (the user’s) and the Signature Date. Then select Submit. Once
the form is complete, the visit will fall off their Scheduled Tasks and the status will
be Completed (Missed Visit).
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EDIT PROFILE
Home/My Account/Edit Profile

If the user knows their current password and/or signature, they can use this
screen to update with new information. If they do not remember their current
signature, it will have to be reset.
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RESET SIGNATURE
Home/My Account/Reset Signature

When users select Reset Signature, a link will be sent to the email address
listed in the message, allowing them to create a new signature.

MY MONTHLY CALENDAR
Home/My Monthly Calendar

Another view of all visits/tasks. Users can select a task that is not yet complete
(Task hyperlink) and chart. Missed Visit Forms are also available to complete
here.
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PATIENT CHARTS
Patients/Patient Charts

Patient Charts can be filtered by:

• Branch - Choose the branch (if more than one branch in an organization).
• View - Status of the patient (Active, Discharged, Pending, Non-Admit).
• Filter - Payer Source.
• Find - Free text to type part of a patient’s name.

The patient’s snapshot at the top of the screen gives a quick view of the patient’s
demographics and information. Select the Patient Profile button to see more
details. A list of visits in the current episode will display at the bottom of the
screen. Filter the Show and Date drop-down menus to change viewing
parameters.
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Select the icon to expand the task view. Select the visit/note if they are not
complete. If they are still a hyperlink in blue, select the task and start charting.
Selecting Menu (under the Actions column) will allow viewing of the Visit Details,
information that is permission based.

VISIT DETAILS

• Scheduled Date - The date the visit was scheduled on the calendar.
• Actual Visit Date - The date the visit was completed. This pulls from the
note the clinician completes.
• Assigned To - The clinician who is currently assigned to this visit.
• Service Location - This is the Q Code that pulls to the claim.
• Personal Notes - Anything documented by the clinician on a mobile
device.
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• Comments (Yellow Sticky Note) - Any notes that pertain to this specific
visit and are needed to communicate with other organization users.
• Return Reason (Red Sticky Note) - Any notes from either QA Center or
another clinician for returned visits.
• Attachments - Upload documents associated with the scheduled task.

QUICK LINKS

Allergy Profile

This pulls a list of all added allergies for the patient. To add an allergy, select
Add Allergy.

Type in the Name of the allergy and the Type of allergy. Select Save & Exit and
the allergy will be added to the report. If there are additional allergies, select the
Save & Add Another button.
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Medication Profile

Add Medication:

• Start Date – Enter manually or select the calendar icon to choose date.
• DC Through Date - Enter manually or select the calendar icon to choose
date.
• Medication & Dosage - Begin typing the description of the medication,
then select Search for Medication. A drop-down box will appear with all
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the medications listed in the software. Medications not listed can be

added. However, only medications selected from the drop-down box will
be checked for drug interactions.
• Amount – example one tab, one puff and one pump.
• Physician - Start typing the name of the physician and the drop-down box
will appear with related physicians.
• Classification - If a medication from the database is entered, this area will
give suggested classifications.
• Frequency - Can be written out fully or with medical shorthand.
• Route - Free text.
• Type - Whether New, Changed or Unchanged.
Decide whether the new medication should create an order or be added to the
medication profile without an order by checking either box. If there are more
medications to enter, select Save & Add Another. If not, select the Save & Exit
button at the bottom. Once a medication is added, it will appear on the Active
Medications. Edit/Delete/Discontinue this medication by selecting the hyperlink
on the right-hand side of the medication.

Check for Drug Interactions:

• Select the Drug Interactions button at the top of the screen.
• Select the box next to the medication on the left-hand side.
• Select Check Interactions. A PDF will generate called Drug Interactions.

Once any updates are made to the Medication Profile, it will need to be signed.
Select Sign Medication Profile in the upper left. A window will pop up with the
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Medication Profile, allowing users to enter their Clinician Signature and Signature
Date. Finish by selecting the Sign button.

To view any prior signed Medication Profiles, select Signed Medication Profiles
and a list will generate.

Select the printer icon to view and/or print the signed Medication Profile.

Immunization Profile

There is a list of inactivated immunizations in the bottom part of the window. To

reactivate, select the Activate hyperlink. To add an Immunization, select the
button in the top left, Add Immunization. Choose the Type of Immunization and
who it was Administered by from their respective drop-down menus. Then write
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in or select the calendar day it was given. Once completed, select the Save
button. Select Save & Add Another if more than one is being entered.

Infectious Disease Profile

The Infectious Disease Profile is designed to help organizations easily track
infectious diseases and screening tools used to detect them. Infectious disease
screenings that have been completed are listed in the Infectious Disease Profile
with the following details:

• User who completed the screening

• Type of screening completed
• Date of the screening
• Screening results

Select the View hyperlink to display the results or select the Delete hyperlink to
remove.

Select the View hyperlink to see the previous screenings or select the Delete
hyperlink to remove. Select the COVID-19 Screening button to add a new
screening. Choose the Person Screened from the drop-down menu. There is a
checkbox if the user Refused Screening. Enter the Reported Temperature.
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Answer the Yes or No questions and choose a Risk Level. Templates and
Additional Screening Requirements may be entered. Select the Screening
Acknowledgment checkbox. Enter the Clinician Signature and confirm the
Signature Date and Time (both auto-generate the time the window was opened).
Users can then Sign Screening, or if there is more than one screening to add,
select the Sign & Add Another to continue with another blank “COVID-19
Screening” window.

Preadmission Notes
Preadmission notes enable organizations to document notes in a patient’s chart
before admitting the patient. Select the View hyperlink to see notes or select the
Delete hyperlink to remove.

Select the Add New Note button to create a note. Enter a Title, Comments and
select the Save button when complete.
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Communication Notes
This report will give a list of all Communication Notes created for this patient.
The report will show who created the note, the date and a PDF to view and/or
print.

Select the printer icon and a PDF document will generate with the ability to print:

Orders and Care Plans

This report will list all the Orders and Care Plans for this patient. This list is a
quick way to view orders when looking for a specific one. The list provides the
basic details of the orders with the ability to view and/or print the document.
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Verify that this is the correct date range. Select the printer icon and a PDF
document will appear with the ability to print.

Plan of Care Summary

Vital Sign Charts

This report pulls a chart of all the prior vital signs documented on visits and a
graphic view of their trends. There is also a Vital Signs Log that shows a
summary list of all the vitals.
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NOTE: The following four Quick Reports are permissions-based.

Authorizations Listing
This report shows all current Authorizations listed for the patient. Authorizations
are typically added by the Biller/Scheduler (Office Staff).

Episode Summaries
This report will list any Intra-Episode Summary that has been auto generated
when a clinician signs an OASIS Recertification, Discharge or Transfer and it has
been reviewed by QA. To narrow down the results, filter by Episode or start
typing the employee who performed the visit, signature or the physician’s name.
Create auto summary by selecting the Create Episode Summary button. The
summary can also be printed as a PDF by selecting the printer icon on the far
right or removed by selecting the Delete hyperlink.
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Triage Classification
This quick report will pull up a PDF version of the patient’s Emergency
Preparedness Plan/Triage Classification based on what was answered during the
assessment. Select the Print button at the bottom to get a copy of the form.

Deleted Tasks/Documents
See Deleting a Visit below

PATIENT CHART TABS

New - Order
To add a new order to a patient’s chart, select New/Order tab at the top of the
patient’s chart and the window below will appear:
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Patient’s name and physician will autofill in the designated fields. Select the
episode this order goes with.
• Date - The date will default to today’s date but can be changed if
necessary.
• Time - Fill in the time.
• Effective Date - This date will default to today’s date but can be changed if
necessary.
• Order is for Next Episode - Check this box if the order will go to the next
episode.
• Summary/Title - Give this order a title.
• Order Types -
o Medication Orders - The Medication Profile will populate, allowing
users to add a new medication.
o Plan of Care Orders - The POC Summary will populate, allowing
users to update the Plan of Care.
o Wound Care Orders – Opens the Wound Orders Profile window.
Users should then select the Add New Wound Order button.
o Discipline Frequency - Discipline Frequency fields will appear at the
bottom of screen to fill in. Remember to check the “If this is an
interim order” box if the new frequency will override the original
frequencies.
o Supply Manager - The Supply Manager box will appear, allowing
users to fill in the supplies.
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o Other - Anything that does not fit in the four types listed will fall in
this field. Anything entered in this type will not flow to the POC
Summary.

New - Aide Care Plan

To add a new Aide Care Plan to a patient’s chart, select the New/Aide Care
Plan tab at the top of the patient’s chart. A new window below will appear.

Choose and/or enter the Aide Care Plan, Things to Report, Special
Considerations, Plan Details and Notifications. Electronically sign after all
information has been chosen/entered and then select the CREATE &
COMPLETE button to complete.

New - Communication Note

To add a new communication note to a patient’s chart, select the
New/Communication Note tab at the top of the patient’s chart and the window
below will appear.
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• Patient’s Name - Auto Filled.

• Episode Associated - Click on the drop-down menu to select the episode
associated with this note.
• Date - Defaults to today’s date but can be changed if necessary.
• Physician - Start typing the physician’s name and a drop-down box
appears. If the physician is not currently in the database, select New
Physician to enter the name.
• Communication Text - This is the area where the Communication Note is
created. Either free text or select one of the organization’s templates.
• Send note as Message - Check this box to send the note as a Message to
other users in the organization.
• Signature - Sign with user’s signature.
• Date/Time - Make sure the note lists the correct date and time.
Select Save to keep what has been entered to complete or edit later. Select
Complete to finish the communication note.

PDGM Dashboard
The PDGM Dashboard empowers organizations with continuous access to real-
time episode data, so users can evaluate key aspects of care delivery for
streamlined intra-episode management. The PDGM Dashboard is accessible to
all users with a role of Case Manager or higher (Clinical Managers,
Administrators, etc.). Financial information on the PDGM Dashboard is visible
based on the user’s financial permissions. To give a user permission to view
financial information, navigate to:
Admin/Lists/Users/*User*/Permissions/Clinical/View Expected Payment for
HHRG_Case-Mix Analysis.
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The top of the dashboard includes:

• Risk Stratification – Identifies the patient’s risk level during the

comprehensive assessment visit (i.e., OASIS). Fall, hospitalization, and
infection risks are identified and updated at recertification. DNR patients
are also identified to alert clinicians entering the patient’s home. DNR
status can be updated using the following path: Patients/Patient
Chart/Edit/Advance Directives
• Plan of Care Summary – Provides current details of the patient’s visit
frequency, medications, and treatment orders. Once the Plan of Care is
approved by QA, the Plan of Care Summary is created and updated
through physician orders or subsequent comprehensive assessments in
real time.
• Plan of Care – Once the Plan of Care is approved by QA, the Plan of Care
that was sent to the physician is now available to view. The Plan of Care is
updated at recertification or Other Follow-Up (SCIC- Significant Change in
Condition).
• View Documents – Enables users to see and access documents attached
to the patient chart.
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Below the top is the Time Period Information which displays the patient’s name,
MRN and the following time period information:

• Episode - The date range comprising the current 60-day episode.

• Start of Care - The day the patient was admitted to the organization.
• Length of Stay - The number of days from the Start of Care date to the
current date.
• Episode Number - The number of 60-day episodes to the current date.
• Days into Current Episode - The total number of days since the start of the
current 60-day episode.
• First 30-Day Payment Period or Second 30-Day Payment Period (top
right) - The current 30-day payment period in the patient’s 60-day episode.

The following tiles appear on the PDGM Dashboard:

• Clinical Alerts - Indicates adverse events throughout care delivery and
facilitates QAPI reporting including Infections, Incidents, Wounds,
Hospitalization and Vital Sign Outside of Parameters.
• Visit Utilization Alert - Indicates when visits may impact compliance. Users
are alerted about missed visits, outstanding supervisory visits for home
health aides, LVNs, PTAs and COTAs.
• LUPA Risk Alert - Displays real-time LUPA risk as low, high, or actual
LUPAs.
• Outcome Potential - Indicates potential for outcome improvement as it
relates to OASIS assessment.
• Home Health Resource Group (HHRG) - Shows the expected payment
and LUPA threshold for each 30-day period.
• Cost Analysis - Enables evaluation of the cost of care delivery and
utilization to date.
• Supplies - Shows the cost of supplies entered by clinicians for the
episode.
• Frequency & Duration – Shows the frequency of all disciplines scheduled
and completed visits including totals for 30 days.

Documents
To manage documents in the patient’s chart, select the Documents tab at the
top of the patient’s chart and the window below will appear.
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Select the New Document button to add any documents/attachments to the

patient’s chart.

Choose files from the computer, give the document a name that will appear in the
patient’s chart and choose the Document Type. Then select Submit when
complete. The attached documents will all display with the ability to Edit or
Delete them by selecting the hyperlinks on the far right.

SCHEDULE ACTIVITY
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The current episode defaults at the top of the screen. All Visits/Tasks assigned to
this episode are listed at the bottom of the screen. Color-coded visits appear on
the calendar and are the print color of the task.

SCHEDULING A VISIT (PERMISSIONS BASED)

Select a date on the calendar and the tab will expand, allowing users to schedule
the visit. The section will also expand by selecting the Show Scheduler tab.

Select the correct discipline’s tab to find a specific visit. Choose the Task and
User in the drop-down menus and fill in the Date. Select Save and the visit will
appear within the list of other Tasks/Visits below. To schedule multiple visits
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(same type) for the same user, select the blue Schedule Manager tab at the top
of screen. Select Schedule Employee, and the box below appears.

Select the specific User/Employee and the Visit Type in the drop-down menus to
schedule. Then select each box in the calendar to assign. If a box is selected
accidentally, select the box again to uncheck. Select Save & Exit and the visits
will display on the patient’s schedule. Select Save & Add Another to schedule
more visits to the same patient.

Visit Details - On the right-hand side of the screen (under the Action column)
you’ll see a Menu drop-down for all visits (these options are permissions based).

Once you select Menu, there will be a Details option. The window will open,
displaying the details of the visit (see Visit Details).

DELETING A VISIT (PERMISSIONS BASED):

To delete a visit, go to the Menu drop-down. Select Delete and the window below
will appear.
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Select OK and the visit will be deleted but still stored in the Deleted
Tasks/Documents in the patient’s chart in case it needs to be restored.

OASIS-D1 START OF CARE:

When charting information in the Start of Care (SOC) visit, some information has
already been pulled from the patient’s profile. Answer all required questions for
the rest of the visit. These are indicated by red asterisks.

• Green Boxes – Information in the green boxes are the M questions that
will be exported to CMS.
• Purple Boxes – These questions generate Plan of Care pathways.
• Grey Boxes – These questions will pull to the Plan of Care (sent to
physician for signature).
• Blue Boxes – Physical Assessment questions.
SOC Orders: Enter orders at bottom of each tab in the SOC. Enter orders,
interventions, goals, homebound status, and medical necessity based on
previous assessment answers. Several boxes will display **. This mark means
the system is requiring customized information, based on this patient’s visit.
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NOTE: For Recert/Resumption Orders, review/update existing orders at the

bottom of each tab in the Recertification and Resumption of Care OASIS
Assessment.

When all information is complete, select the CHECK FOR ERRORS button. A
window will open showing any warnings, errors or conflicts.

Warnings will have a yellow triangle icon. This message is letting users
know of things they may want to look at before submitting the OASIS, not a hard
stop. An error will be a red stop icon. This message lets users know this
question either needs to be answered or answered differently. Users cannot
finish an OASIS with red error messages. The final screen will show the
calculated Home Health Resource Group (HHRG) and OASIS Case-Mix
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Analysis. Once the OASIS is complete, the system will automatically create a
485 Plan of Care if the Create Medicare Plan of Care toggle is selected.

Before finishing the OASIS, users can run the OASIS Scrubber by selecting the
button in the bottom left (PDF will be generated). Axxess has an
integration/interface in place with SHP for OASIS Audits. This will look for any
inconsistencies or flags that the organization may want to address. These audits
are not necessarily wrong, the scrubber is looking for inconsistencies.

After all audits have been addressed, ensure Time In and Time Out is completed.

NOTE: If the organization tracks travel time, then surcharges and mileage must
also be entered.
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Enter the Clinician Signature, confirm Signature Date and Signature Time, then
select Finish. Once the OASIS is finished, it will be sent to the QA Center for
approval. The Plan of Care will then generate in the patient’s schedule.

HELP CENTER
A great resource available any time, any day is our Help Center. Get answers to
frequently asked questions and watch tutorial videos on all our Axxess products.
Our Help Center can be accessed by going to Help/Help Center or
https://www.axxess.com/help/