Completing Assessments

How to complete an assessment in the Assessments / Fluid Balance section of the patient record. Additional guidance regarding how to use keyboard controls when completing assessments can be found here.

1. Select the relevant navigator band from the left hand column e.g. Adult Quick View.
2. Select the relevant section within the band e.g. Measurements.
3. Start the assessment by double clicking at the top of the relevant time column next to the name of the section, this will:
   • Add a tick indicating that the section is ready for data entry.
   • Move your mouse into the first field in the section so you can start documenting.
   • Activate any calculated fields.

4. Once the tick is added, the first answer box will automatically open. Answers can be:

Single select list – Choose an answer, the next item will open automatically
Multi select list – Click the answer(s) to tick them and then press Enter or Tab or click the ‘X‘ in the corner of the box to move on
Free text – Type in the answer and then press Enter or Tab or click into the next field to move on
Time/ Date – pressing T on the keyboard will default today’s date and the current time into the field. Press Enter to move on
Staff look-up – enter the name of the staff member you wish to search for then click the magnifying glass icon

5. Some sections might contain guidance or icons:
   • Reference Text – Click the link to read associated the guidance.
   • Conditional Field – Conditional field trigger – may populate further assessment fields depending on answer given.
   • Related to conditional field – indicates this field has been triggered due to the answer in a conditional field.
   • Calculated field – indicates field is automatically calculated. Hover on the calculator to see which data it relates to.
   • Repeatable group – allows the assessment to be record against a labelled group.
6. As you complete fields they are shown in purple. Purple indicates an unsigned entry.
7. When you have finished click the sign button (green tick to the top left) to confirm and save your entries.
8. Signed entries will now display in black text.