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Creating a New Nursing Assessment

Learn how to create a new nursing assessment. The nursing assessment needs to be set up in the Community Record before a new nursing assessment can be created. See the Setup: Nursing Assessment and Service Plan help topic if not set up yet. Scribe Link: https://scribehow.com/shared/How_To_Complete_A_Nursing_Assessment_Online__FGaWBq-QTmC7UR5xUheyGw

Navigate to the Nursing Assessments

  1. Click "Select Resident" under the "Resident" tab.
  2. Select a resident.
  3. Click "Nursing Assessment" under the "Nursing" dropdown.
  • All nursing assessments for this resident are displayed here.

Create a New Nursing Assessment

  1. Click the "New Entry" button.
  2. Fill out the form.
    • The sections selected in the setup phase will determine which sections display on this form.
    • The "Next Review Date" is automatically updated according to the number of days chosen in the setup phase.
    • Select the type of assessment.
    • Whenever the "No signs…" button is selected a text box will appear, populated with the text entered during the setup phase. The text is editable on this form.
    • Some sections have additional, more detailed evaluations.
      • There is a button at the end of each of these sections that will lead to the additional evaluation.
      • When the button is clicked, a new form will be opened.
      • After filling out the form, click the "Save" button.
      • The page will automatically return to the nursing assessment that was being filled out.
    • Some sections have a "Level of Assistance" dropdown. These sections are always associated with a service plan. Information added to these types of sections will automatically be added to the resident's service plan.
    • Click the "Save" button to save progress made on the nursing assessment.
  3. Select the "Completed Nursing Assessment" button, and click the "Save" button to save the nursing assessment and finish. Once the nursing assessment has been saved like this, it will be locked. A service plan will be generated based on the data entered in the nursing assessment.
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