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Add an Assessment

Adding an assessment is quick and easy, and it allows you to thoroughly document a patient's condition throughout the run. When you add an assessment, you have the option of including information about the patient's vitals, neurological or mental status, pupil reactions, skin condition, breath sounds, injuries, and/or stroke scale test results.

To add an assessment in Windows

Tip: If the information in some of the fields is not applicable or cannot be supplied, tap the Not Value button. From the list in the pop-up window, select a reason for not capturing information for the given field.

TTCDX_not_value_button_field.png

  1. In the side navigation of an open run record, tap Assessment. The section expands.

    assessment_section.png

  2. Directly below the Exam section, tap Add Assessment. The New Assessment window opens.
    TTWin_newassessment.png

  3. Enter information in the fields using any of the following methods:

    • Using the stylus.

    • Tapping a field to type in an entry.

    • Selecting options from a window that opens.

  4. Optionally, to clear a selection made in a pick-list window:

    • Tap in the field.

    • In the upper right corner of the newly opened pick-list window, tap CLEAR.

    • Tap OK.

  5. To re-enter or clear the information in a single field, tap the clear icon.

  6. Repeat steps 3-5 as needed and applicable for the Vital SignsMental/Neuro, Pupils, Skin/Perfusion, Breath Sounds, Systemic, and Stroke tabs. See Assessment Fields for detailed descriptions of specific fields and shortcuts that can help you compete certain sections.

  7. Tap OK. The assessment and its details appear in the assessments table.

    TTWin_assessmenttable.png

  8. To verify all required fields are completed, check the record for errors.

To add an assessment in Web

Tip: If the information in some of the fields is not applicable or cannot be supplied, tap the Not Value button. From the list in the pop-up window, select a reason for not capturing information for the given field.

TTCDX_not_value_button_field.png

  1. In the side navigation of an open run record, click Assessment. The Exam subsection is displayed.

  2. Go to the Assessment subsection and click Add Assessment. The New Assessment window opens.
    TTCDX_newassessmentwindow.png

  3. Enter information in the fields using any of the following methods:

    • Clicking a field and typing in an entry.

    • Clicking a field and typing the first few letters of the value you want to enter. When a list of matches appears beneath the field, select the appropriate option.

    • To enter more than one item in fields that allow multiple values, continue typing in the field and select a new item.

  4. Optionally, to clear a selection or entry, click the x next to the entry.
    TTCDX_clearselection.png

  5. Repeat steps 2-4 as needed and applicable for the Vital SignsMental/Neuro, Pupils, Skin/Perfusion, Breath Sounds, Systemic, and Stroke tabs. See Assessment Fields for detailed descriptions of specific fields and shortcuts that can help you compete certain sections.

  6. Click Save.

  7. Tap OK. The assessment and its details appear in the assessments table.

Note: If you entered information about the patient's vitals in the Vital Signs tab, that information appears as an event in the Events section.

To manage an assessment, click the Actions button associated with the assessment. From the menu that opens, you can edit the entry by clicking Edit, delete the entry by clicking Delete, or copy the assessment by clicking Copy or Copy+Edit.

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