Patient Chart: Assessments

The following topics are discussed on this page. Use the links to jump to the desired subject:

ntroduction to Assessments

To change the view

Working with Assessments

To copy an assessment from a previous visit

To add an assessment

To edit an assessment

To compare assessments

To view the change log

To print assessments

Setup considerations: Usage of the Assessment page requires setup in additional locations. Click here to view a list >> [+]

Introduction to Assessments

The Assessments page is used to document and view the patient's physical assessments completed by the clinician. The Assessments page lists existing assessments and allows you to add a new assessment using the Assessment field. Existing assessments are listed with the most recent assessment at the top. You can filter the list by using the Filter and Sort fields.

• Use the Filter field to display assessments by type. In the Filter drop-down list, select the type(s) of assessments that you would like to display.
• Use the Sort field to sort the list alphabetically by Assessment name or in reverse chronological order (most recent assessment first) by Charted Date/Time. Select the desired option in the Sort field.

To change the view

Use the expand button (black double arrow button located by the Actions link), to display additional fields used to change the view: View, Start Date, and End Date. Since the default view is for the current visit, use the View field to select other options: Recent Visits, Date Range, or All Visits. If you select Selected Visit or Date Range, use the Start Date and End Date fields to specify the time period to view. If you select Recent Visits, enter the number of visits in the next field. Then, select the types of visits to display in the third field.

To save your filter settings, go to Actions > Save Filter Settings. This saves the current settings as a default for future visits to the page. Note: This feature is controlled in User Administration by the Hospital - Patient Chart - Save Filter Settings security item.

Working with Assessments

There are 5 function buttons to the right of each assessment:

Partial Assessments (Status column)

If required fields/elements of an assessment are not completed, the word "Partial" is displayed in the Status column. To edit/complete a partial assessment, click the Edit button and complete the required fields. In addition, the following occurs for Partial Assessments:

• "Partial" assessments are displayed in the Clinician Work Center as a reminder to complete them.

•  If an assessment is at "Partial" status, then that is indicated on the Assessment Report (using the Print button on the Assessment page), located just below the Assessment Name.

• A report is available in Reports > General > Partial Assessments Report, that can be run to list the "partial" assessments that need to be completed. The report can be run by Unit(s) or by My Patients.

Cosigning Assessments

The Assessments page allows cosigning of assessment entries for providers, similar to the cosigning of transcribed documents. Mid-level providers (MLPs) can create the assessment, select a Supervising Provider to route the note to, and have a Supervising Provider cosign the assessment.

• In the PWC, a Documentation Needing Cosign section displays assessments and chart notes that require a co-signature.
• In Dr. Signature, a Documentation Needing Cosign tab displays all Assessment and Chart Note items that require a co-signature. From this list, the provider can Sign, Reject, Edit, Reassign, and/or Print the note/assessment.
• A report, Documentation Cosign Report, is available on the General Reports page. 
• The Change Log contains the audit trail for the activities of cosigning Assessments and Chart Notes. 
• Use the Maintenance > Specific Application  Setup settings for Clinic > Auto Sign Parameters for Documentation and Hospital > Cosign Parameters for Documentation to define preferences and defaults.

Additional Information regarding Cosigning functionality:

• A user cannot edit the note/assessment from the PWC if he/she is not the creator of the item.

• A user can re-assign a note/assessment from the PWC only if he/she is the creator or cosigner of the item.

• A user can sign/reject the note/assessment from the PWC only if he/she is the cosigner of the item.

To copy an assessment from a previous visit

Assessments can be copied from previous visits to the current visit.

1. Use the options in To change the view to display previous visit assessments.

2. Click the View Assessment button (magnifying glass) to display the assessment.

3. Click the Copy to Current button.  The Original assessment is displayed on the right side of the screen and the Current copied version is displayed on the left side of the screen for comparison and editing, if desired. To hide the original from the screen, click the Hide Original button.

4. Click Save on the Current Assessment to save to the current visit.

To add a new assessment

1. From the Assessments page, type the first few letters of the assessment you are looking for in the  Assessment field. Existing matches to your typed text are displayed.

2. Select the desired assessment by clicking. The name of the assessment is displayed in the Assessment field. (Tip: After selecting the appropriate assessment, you can press <Enter> to "add" the assessment and bypass step 3.)

3. Click the Add Assessment button (green plus sign) to display the detailed assessment page.

Optionally, you can click Admission located at the top of the screen to display the default admission assessment.

4. At the top of the assessment and the top of each section, you have two or three options (based on whether this is a new or repeat assessment) for completing each section of the assessment: WNL (within normal limits), Chart by Exception, or No Change (only available if a previous assessment exists).

   • WNL: Selecting this option at the top of the assessment page automatically populates the normal findings for the entire assessment. Selecting WNL at the top of each section automatically populates the normal findings for that section of the assessment as previously set up.

   • Chart by Exception: This option allows you to go to address each field and select the appropriate response.

   • No Change: This option (only available on subsequent assessments) allows you to copy the responses from the previous assessment.

5. If a previous assessment exists, you can click Show Details button (magnifying glass), located at the top right of the screen, to display the previous assessment values to the right of the new assessment.

6. Complete the assessment findings by selecting responses to the desired fields. Depending on the assessment that you select, the following features may be available:

5. • Braden Scale: To use the Braden Scale, click Braden Scale. The Braden Scale box is displayed. For each of the rows (Activity, Friction and Shear, Mobility, Moisture, Nutrition, and Sensory Perception), check the appropriate level for the patient. Click Save. You are returned to the Assessment page and the calculated Risk Value is displayed.

5. • Vital Sign: Click the Vital Sign button to display the Add Vitals window, and enter the vitals information. Use the keyboard's mouse to roll over each field to display valid input values. In the Pain Scale field, you can use the drop-down list to select the level of pain, or you can click Use next to FLACC Scale or Wong Baker Scale to use one of those scales instead.

5. 1. • Wong Baker Faces Pain Scale: Select the appropriate face indicated by the patient and click Save. The appropriate value is displayed in the Pain Scale field.

      • FLACC Pain Scale: Choose the correct option in each of the Face, Leg, Activity, Cry, and Consolability rows and click Save. The appropriate value is displayed in the Pain Scale field.

Once you have entered all appropriate values, click Save. The Vital Sign button on the Assessments window is updated with the date/time of the last vitals entered.

5. • NIH Stroke Scale: In the NIH Stroke Scale section, click the NIH Stroke Scale button. The Add Stroke Scale window is displayed. Make the appropriate selections for each row of the grid. Then, click Save. When you return to the Assessment page, the Risk Value is displayed based on the selections made.
     

   • Glascow Coma Scale: In the Glascow Coma Scale area, click Use to display the Glascow Coma Scale box. For each row, select the appropriate level of the patient. Then, click Save. You are returned to the Neurological assessment page and the scale is displayed.
     

   • Pediatric Glascow Coma Scale: To use the Pediatric Glascow Coma Scale, click Use to display the Pediatric Glascow Coma Scale box. For each row, select the appropriate level of the patient. Then, click Save. You are returned to the Neurological assessment page and the scale is displayed.

7. REQUIRED ITEMS/PARTIAL ASSESSMENTS: Complete the remaining items of the assessment, as needed. Required items are marked with an asterisk (*). If you proceed to step 8 without completing required items, you are notified via message that required items still remain. Click Save Partial to proceed to save the assessment in a Partial status resulting in the following actions:

   • The word "Partial" is displayed on the Assessment page in the Status column. To edit/complete a partial assessment, click the Edit button and complete the required fields.

   • "Partial" assessments are displayed in the Clinician Work Center as a reminder to complete them.

   •  If an assessment is at "Partial" status, then that is indicated on the Assessment Report (using the Print button on the Assessment page), located just below the Assessment Name.

   • A report is available in Reports > General > Partial Assessments Report, that can be run to list the "partial" assessments that need to be completed. The report can be run by Unit(s) or by My Patients.

8. Click Sign. When the assessment is signed, a box is displayed with suggested care plans based on the assessment findings. Uncheck the care plan problems that you don't want to add to the plan of care. Click Save. (See Also: Plan of Care) When suggested problems have been added, the View Details icon is displayed on the Assessments page next to the assessment name.

To cancel an Assessment

If you wish to cancel the assessment and not save your entries, click the Cancel button. A notification message is displayed: How would you like to proceed? Click Discard Assessment to leave this page and not save any of your entries. Or, click Continue Working to go back to the Assessment and continue and save the assessment using the Sign button.

NOTE: When abnormal assessments have been entered, an Abnormal Assessment Note is automatically added to the Chart Notes page.

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To edit an assessment

1. Click the Edit Assessment button next to the assessment that you want to edit. The selected assessment page is displayed.

2. Review the Current Date/Time fields and modify, if necessary, using the calendar and clock widgets. (This date and time is the time that will be associated with the newly modified assessment.)

3. Then, you can do one of the following:

1. • To mark the assessment as an error and have it removed for the patient record, click Mark Erroneous. The Edit Note box is displayed.

   • To make changes to the selected assessment entry, modify the desired field(s). See To add a new assessment for details on completing the assessment forms. Then, click Update.

4. In the Reason field, use the drop-down list to select the appropriate reason you are removing or editing the entry.

5. Click Save. You are returned to the Assessments page.

To compare assessments

From the Assessments page, you can compare assessments (only like assessments will be compared, i.e. chest pain assessment to chest pain assessment) by clicking the Compare button located to the right of the assessment. Then, use the right and left arrows to scroll through the existing assessments.  Click Close to close this window and return to the Assessments page.

To view the change log

From the Assessments page, you can view changes made to an assessment by clicking the Change Log button located to the right of the assessment. Details regarding user actions on the Assessment page, including entered date/time, user name, flowsheet, charted date, reason, and actions are displayed.   

Or, you can click View Change Log at the top of the Assessment page to view changes to all assessments in succession. When using this option, you can use the Filter and Sort fields to view specific assessments.

• In the Filter field, use the drop-down to select All, Added, Edited, or Removed.

• In the Sort field, use the drop-down to select Date/Time or Charted Date.

The list of assessments is displayed according to the entered criteria.

Use the magnifying glass button to toggle between hiding and displaying the details for each assessment. Click Close to close this window and return to the Assessments page.

To print assessments

On the Assessments page, click the Print button located next to the assessment that you want to print. The Assessment is displayed in a preview. Click the printer icon button to print to a printer.

Finished on this page?

Once you are finished on the Assessments page, you can navigate to other areas using the carousel options at the bottom of the page in the green bar. To go to the Main page, click the underlined Main link. Or, to go to Home Medication or CPOE, click the links located in the left or right corner, respectively.

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