Adding a Patient Assessment

1.   If you haven't already, select the patient and go to the Infusion Flowsheet module.

Note: Patients treated at both MGH and the DFCI may have more than one flowsheet. If so, you need to click the desired flowsheet and click Ok (ALT+O) to continue.

2.   Click the Patient Assessment heading to expand it.

3.   Click the blue dashes (----) for the visit date. The Patient Assessment Flowsheet screen displays.

4.   Click headings to expand categories.

5.   To add an assessment for any category, click the blue dashes (-----) to the right of the heading name for the visit date. The flowsheet allows you to record an assessment for today as well as since the last visit for each category. The previous entry is displayed for informational purposes.

6.   Record your assessment by selecting options and typing text, as appropriate. If Comments/Interventions have been added for previous visits, they are displayed in the lower right. Click a date to "import" (copy) text from that visit. Click Ok (ALT+O) to complete a category.

Note: You are not allowed to import information from a previous visit if a different version of the patient assessment was used to document that visit.

7.   When you have completed your assessment, click Go Back (ALT+G) to return to the main screen and Sign. The LMR indicates the changes that will be saved. Type your key and click Sign.