Assessments

Before you start

Every visit gets a chart with two forms, built from the service's templates (see Form Templates):

• Assessment: completed before treatment. Needs a role that can manage orders, such as a nurse practitioner or medical director.
• Intervention: what was given. Only the provider on the visit can edit it.

Step 1: Open the chart

1. Open the appointment from Appointments or the Calendar.
2. Select Chart Notes.
3. The Patient tab shows their details, clinical record (allergies, conditions, immunizations), vitals, orders, signed consents and visit history. Select Add record under Vitals to log blood pressure, pulse and more.

Step 2: Complete the assessment

1. Select the Assessment tab, then Edit form.
2. The service's medication protocol is filled in. Adjust doses if needed, or set Apply protocol to No.
3. Answer each question, then select Save changes.

Step 3: Sign and lock

When it's complete, select Sign and lock. The signed chart is saved to the patient's record and shows who locked it.

A locked form can't be edited. Someone with full EMR access, or the person who locked it, can unlock it.

Step 4: Record the intervention

1. Select the Intervention tab, then Edit form.
2. Record what was given, save, then Sign and lock.

No Edit form button? If the service requires an order and none is on file, the intervention stays locked. Add an order under Patient > Orders (see Medical Orders).

Tips

• Use Attachments on a form to add photos or documents.
• Use Notes at the bottom of a form for anything that doesn't fit a field.