Document a Patient Assessment
A Patient Assessment, found under Nursing Care, is where you enter symptoms and related comments reported by the patient. Pain, Fatigue, Cough, Breathing Changes, and many more patient-reported symptom assessments can be recorded at once.
Each symptom has 3 options:
NA or not assessed
No or negative
Yes or positive
Document Positive Symptoms
When you choose Yes for a symptom, you are able to enter additional details about that symptom.
For Pain, choose the Pain Scale finding and enter related comments.
Use Other to record assessments for symptoms not listed in the Patient Assessment section.
Document Using an Edmonton Symptom Assessment
To enter an assessment using the Edmonton Symptom Assessment System (ESAS), click EDMONTON SCALE.
View Previous ESAS
To see the previous ESAS entry, click View Most Recent.
Each symptom is assessed on a 0 to 10 scale. Click the number reported by the patient. Enter related comments using free text.
To erase an assessment, click Clear.
After charting the ESAS, click SAVE. This returns you back to the Patient Assessment.
Save a Patient Assessment
When you have completed charting all symptoms the patient displayed or reported, click SAVE.
Electronically Sign a Patient Assessment
If you are required at your practice to electronically sign the Patient Assessment, click SIGN and enter your PIN.
View Electronic Signature
Once signed, your name and the sign date show next to Patient Assessment.