Appendix D. E-transitions Sample Screen Shots

Development of Electronic Transition Tools for Home Health Care

This appendix presents examples from the e-transitions Web site used in training materials for Cornell-NYPH physicians and VNSNY nurses during the pilot testing phase of this project. Note: All patient information on these pages is fictitious.

Figure D.1. E-transition Web Site (Home)

Screenshot showing the home page. The physician or nurse is prompted to select the 'Login' button at the upper left hand corner and enter an assigned User Name and Password to access the user's personal page. On the right-hand side of the screen is an empty box saying 'News Flash' and below it one saying 'Current News'. There is also a 'Tips' link and a link to register.

From the e-transitions home page (Figure D.1), the physician or nurse is prompted to select the "Login"; button at the upper left hand corner and enter an assigned User Name and Password to access the user's personal page. A list of patients currently receiving home care from VNSNY acute care teams will appear on the physician's home page; similarly, a list of patients referred by participating physicians at the Cornell-NYPH will appear on the nurse's home page (Figure D.2). 

Figure D.2 Sample screen shot: nurse's personal (home) page

Sample screen shot showing a nurse's personal home page for their patients. Fictional patients are in a list. The column headings include: Name, Patient Status, Physician, Primary Doctor, Team, New Info, Viewed, and Discharged

When a patient is added to these lists or if there is new information or revisions to orders for a current patient, the user is alerted through e-mail. To view or revise orders for a patient, the user selects the patient's name and is directed to the plan of care page.

Plan of Care Page for Current Patients

The patient's plan of care orders are listed in date order, with the most current working plan at the top (Figure D.3). 

Figure D.3. Sample screen shot: plan of care page

Sample screen shot of a plan of care page for an individual patient. It is divided vertically into different sections. The first section is called 'Plan of Care and Current Orders' and includes a list of documents. The second section is entitled 'Revisions to Current Orders' with columns including Category and Changes and a Sign-off link. The third section is entitled 'Notes from the Nurse', and there is the top of a section called 'Notes from the Physician'.

By selecting "CMS-485"; the user can access a complete and printable plan of care (Figure D.4). 

Figure D.4. Sample screen shot: patient's plan of care

Sample screen shot of a patient's plan of care page from an individual physician. It includes sample patient and provider personal information and diagnosis, medication and treatment information.

Other options from the plan of care page include:

Figure D.5. Sample screen shot: editing patient's demographics

Sample screen shot of a page where you can edit a patient's demographic information. The fields you can edit include first, middle, and last name; gender, birth date, address, primary insurance, Social Security number, and MRN/Case number.  

Figure D.6. Sample screen shot: adding a new order

Sample screen shot of a page where you can add a new order for an individual patient. On the screen is a lettered list with sections A-F on the patients' medications, allergies, functional limitations, mental status, prognosis and goals. Section G is further subdivided into individual sections for order types including nursing services, lab requests, supplies, nutritional recommendations and treatments. Section H below that is a discharge plan.  

Figure D.7. Sample screen shot: adding a note

Sample screen shot of a page where a nurse can add a note. There is an empty text box to add information and above it a checkbox to indicate that the note is high priority. Below the text box is an orange button to save the note.  

Figure D.8. Sample screen shot: signing off on changes

Sample screen shot of a page showing a fictional signing off of a patient. In a text box it says '21. Orders for Discipline and Treatments New- 2 times per week for 8 weeks', and to the right-hand side an orange Submit button.

Making a New Referral to Home Care

The physician can refer a patient and create a plan of care from his or her personal home page (Figure D.9) by selecting "Add a New Patient." 

Figure D.9. Sample screen shot: physician's personal (home) page

Sample screen shot of a physician's personal page showing a list of their current patients. The columns on the top include: Name, Insurance No, Order Status, Home Healthcare Agency, Primary Dx, Renew Orders, New Info, Inactivate, Send Info to HHA, and Transfer to another MD'. There are also links below the fictious patient list for 'List of Info Sent to HHA', List of Pt transferred to another MD', and 'List of Inactive Pt'. To the right-hand side is a link to add a new patient.

This directs the physician to a set of pages where the patient's demographic information, care plan, goals, and other data are input. Figure D.10 illustrates the final page of the set. 

Figure D.10. Sample screen shot: new referral page

Sample screen shot of a referral page for physicians to refer patients to another physician. It includes a box where the physician can use a digital signature to sign off on the referral. There is also a text box for notes for the nurse. At the bottom of the screen are checkboxes for the physician to indicate what information a patient can view including goals, safety measures, activities permitted, and medications and monitoring.

Page last reviewed September 2007
Internet Citation: Appendix D. E-transitions Sample Screen Shots: Development of Electronic Transition Tools for Home Health Care. September 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/hcbs/etransitions/etransitionsapd.html