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Nurse: How to Complete the Nursing Assessment

How to Display the Nursing Assessment Page

  1. With an active client selected, click the Search icon.
    1. See General Client Search for details on opening the active client’s record.
  2. Type ‘Nursing Assessment’ into the search bar.
  3. Click to select Nursing Assessment (Client).
  1. The assessment screen opens.

If a previous assessment exists, a PDF copy of the last completed assessment will be displayed instead.

How to Create a New Nursing Assessment

  1. Begin on the Nursing assessment page.
  2. Select the New icon. A new assessment will open.

How to Complete the General Tab of the Nursing Assessment

  1. Open a new assessment or click to edit an existing assessment. The General tab will open.
  2. Complete the required fields in the Demographics section. The checkboxes for Client Check with Clothing/Pockets and Body Search Completed with RN, as well as the Witness field, will only initialize if Is this Client Inpatient is set to Yes. 
  3. Select the Save icon and navigate to the next tab.

How to Complete the Vitals Tab of the Nursing Assessment

  1. Begin on the Nursing Assessment.
  2. Select the Vitals tab.
  3. Complete required fields in each section by importing the most recently-completed vitals flow sheet. Click the Open Vitals Flow Sheet button to complete one, if needed. For more information, see Flow Sheets training.   
  1. Select the Save icon and navigate to the next tab.

How to Complete the Allergies tab of the Nursing Assessment

  1. Begin on the Nursing Assessment.
  2. Select the Allergies tab.
  3. Complete required fields in each section by importing Allergies and Current Medications from SmartCare RX. For more information, see SmartCare RX training. Optionally, add comments. 
  1. Select the Save icon and navigate to the next tab.

How to Complete the Systems Tab of the Nursing Assessment

  1. Begin on the Nursing Assessment.
  2. Select the Systems tab.
  3. Complete required fields in each section by selecting a radio button for each system, then selecting relevant checkboxes for each system where symptoms are present. Optionally, complete comments fields.
  1. Select the Save icon and navigate to the next tab

How to Complete the D&A Tab of the Nursing Assessment

  1. Begin on the Nursing Assessment
  2. Select the D&A tab.
  3. Complete required fields in each section.
    1. For the Substance Use section, select a checkbox beside each general statement that the client indicates is true and select a radio button for Client has a history of withdrawal symptoms. Optionally, add comments.
    1. For the History and Current Use of Substances section, select the checkbox beside each drug or drug category the client uses. Select the Family Hx button to add a Family History, if applicable. Type Age of First Use and select a Frequency and Route from the dropdowns. Type or select a Date Last Used, indicate if the drug was initially prescribed by selecting the checkbox for drugs that were initially prescription drugs, and enter a numeral in the Preference field.
  1. Select the Save icon and navigate to the next tab

How to Complete the Nutrition Tab of the Nursing Assessment

  1. Begin on the Nursing Assessment
  2. Select the Nutrition tab.
  3. Complete required fields in each section by selecting radio buttons, entering text in text box fields, and selecting checkboxes for appropriate needed referrals.
  1. Select the Save icon and navigate to the next tab.

How to Complete the Crisis Management Tab of the Nursing Assessment

  1. Begin on the Nursing Assessment
  2. Select the Crisis Management tab.
  3. Complete required fields in each section. Fields will only initialize if you set Is client in Inpatient, C&A Residential, or C&A Day Hospital? To Yes. Once initialized, select Radio Buttons, check appropriate checkboxes, and enter comments in comments in text fields where appropriate
  1. Select the Save icon and navigate to the next tab.

How to Complete the Pain Tab of the Nursing Assessment

  1. Begin on the Nursing Assessment
  2. Select the Pain tab.
  3. Complete required fields in each section. Pain Location assessments will only initialize if Yes is selected for either Do you currently have pain? or Have you had pain in the past 2 months? Select from dropdowns, enter text in fields, and select appropriate checkboxes.
  1. Select the Save icon and navigate to the next tab

How to Complete the Edmonson Psychiatric Fall Risk Assessment Tool Tab of the Nursing Assessment

  1. Begin on the Nursing Assessment
  2. Select the Edmonson Psychiatric Fall Risk Assessment Tool tab.
  3. Complete required fields in each section. Select all applicable checkboxes. The score will update automatically at the top of the assessment tool.
    1. A score over 90 indicates a risk of falling.
  1. Select the Save icon and navigate to the next tab.

How to Complete the Sexual Patterns Tab of the Nursing Assessment

  1. Begin on the Nursing Assessment
  2. Select the Sexual Patterns tab.
  3. Complete required fields in each section. The In Past/Currently radio buttons only initialize if the Has client ever been sexually active? question is set to Yes. The birth control dropdown selector only initializes if the Is client using birth control? question is set to Yes.
  1. Select the Save icon and navigate to a remaining tab, or Sign the assessment

How to Complete the Summary Tab of the Nursing Assessment

  1. Begin on the Nursing Assessment
  2. On the General tab, ensure that the ‘Is this client Inpatient?’ radio button is set to Yes.
  1. Select the Summary tab.
  2. Complete required fields in each section. Enter text in the Narrative box, or select the Unable to Complete Assessment. Check each Facilities checkbox that has been completed.
  1. Select the Save icon and navigate to a remaining tab, or Sign the assessment. For more information, see How to Sign a Document.