Completing Patient Assessments

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Completing Patient Assessments

Note: Your Staff Manager configuration may not include this optional application. To add this application to your configuration, contact your Clinical Consultant or Client Advocate.

Completing a Patient Assessment by Direct Entry

Complete the following steps to complete a patient assessment by direct entry:

From the Acuity menu, select Patient Assessment. The Patient Acuity Assessment page opens.
Select a facility from the menu in the Navigation Pane, if applicable.
Select a profile/location in the Navigation Pane.
Select a patient’s name from the Patient List.
If you want, you can select a Patient Filter Setting.
- Show Current displays all patients on the selected profiles and locations as of now, according to the patient location list maintained by the Registration Import.
- Show Recent displays only those patients who were in one of the selected locations within the past eight hours, but who are currently in a different profile/location.
Edit the Assessment Date and Time, if necessary. The page uses the current date and time by default; if the date and time are correct, you should proceed with the assessment. If you are backdating the assessment, you should enter that date and time. The date and time you enter cannot be more than eight hours from the current date and time.
If the page is displaying Staffing Ratio boxes (RN, LPN/LVN, and UAP) or Patient Type buttons, you should complete those boxes as outlined in Acuity Staffing Validation with Patient Assessments and Audits.
Using the outcome set buttons, select the Likert rating that best matches the patient’s state.
- For all outcomes, the Likert rating on the far left is the worst possible state for the patient while the Likert rating to the right is the most desirable state.
- If the outcome is not relevant for this patient, select Does Not Apply. For example, when assessing a comatose patient, it would be appropriate to select Does Not Apply for the outcome Knowledge: Disease Process.
- You can select only one Likert rating per outcome.
- Deselected Likert ratings have a white background. Selected Likert ratings have a blue background.
- To deselect a Likert rating, select it again or select a different Likert rating for the same outcome.
When finished selecting Likert ratings, select a Save option.

If you have assessed the patient against all the outcomes that apply (that is, the assessment is complete), select Save (Complete).
If the results of this assessment are the same as the last assessment (that is, you did not have to change any of the Likert selections), select Save (Same as Last).
If unable to complete the assessment, select Save (Finish Later). This saves the assessment as incomplete and lets you (or a different user) complete the assessment later.
To cancel any changes made without saving them, select Cancel.

Once the save is complete, the page refreshes and the last assessed date and time change to the Assessment Date associated with the assessment.

More Information about the Patient Acuity Assessment Page

The outcome set list is sorted alphabeticly.

The page displays each outcome with its description in the first column, followed by five buttons showing the specific Likert scale values associated with that outcome.

To determine the scope of the outcome that you should consider using nursing judgment, you can select an outcome to see a list of its indicators. These indicators can then assist you in selecting the appropriate Likert value.

The application records the name of the person saving the assessment and whether the assessment is complete or incomplete. If an assessment is started by one person and completed by another, the application records the name of the person who completed the assessment. Clairvia Web also records whether a user filed the assessment by direct entry or whether a clinical documentation interface completed the assessment. Direct entry assessments have the letters DE listed after the Last Assessed date and time, while assessments completed by the interface have the letters IF. These notes are displayed on both the page and the Printable View.

The New button is between the Save buttons and the Cancel button. You should select New when, after selecting a patient to assess, you find an incomplete assessment from another user and want to complete a fresh assessment of your own, not the previous user’s assessment.

The following table outlines common assessment situations and their options.

Assessment	Outcome Set	Available Options
First assessment for a location or a location and hospital service combination	Deselected (all buttons are white)	Save (Complete) once you have assessed all outcomes that apply. Save (Finish Later) once you have changed some of the outcomes that apply. Cancel.
Last assessment is incomplete	Partially selected (some buttons are blue)	Save (Complete) once you have assessed all outcomes that apply. New if you want to begin a new assessment.
Subsequent assessments, same location and hospital service	Previous selections display	Save (Complete) once you have assessed all outcomes that apply. Save (Same as Last) if current outcomes match the previous assessment. Save (Finish Later) once you have changed some of the outcomes that apply. Cancel.
New location or new hospital service	Deselected (all buttons are white)	Save (Complete) once you have assessed all outcomes that apply Save (Finish Later) once you have changed some of the outcomes that apply. Cancel.
Audit (See Completing Patient Acuity Assessment Audits for more information.)	Deselected (all buttons are white)	Save (Complete) once you have assessed all outcomes that apply. Cancel.

Completing a Patient Assessment with a Clinical Documentation Import Interface

Clients with Electronic Clinical Documentation (ECD) applications complete patient assessments automatically using an interface from their application. ECD applications can be NOC-based or non-NOC-based. An ECD interface can send data to Staff Manager via a batch file at pre-set intervals or send the data via the Registration Import.

NOC-based interfaces receive Likert ratings at the NOC Indicator level to complete patient assessments and determine the target staffing for each patient.

Non-NOC-based interfaces receive select clinical observations, interventions, and lab values from the ECD application. The interface then maps this data to Likert ratings at the indicator and NOC outcome level. Staff Manager uses this data to calculate each patient’s acuity level.

How the Patient Assessment Pages Display Interface Information

The Patient Acuity Assessment and Patient Acuity Assessment Audit Pages

The Assessed By cell reads Clindoc when an interface generated the patient assessment. You should not perform manual patient assessments when the interface is running.

Staff Manager selects the Does Not Apply rating automatically if it does not receive data for an outcome from the interface. It also highlights the Does Not Apply button when the pull forward period expires.

Both the Patient Acuity Assessment and the Patient Acuity Assessment Audit pages show whether a user or an interface completed an assessment. Direct entry assessments by users have the letters DE after the Last Assessed date and time, while assessments completed by the interface have the letters IF.

The Patient Acuity Assessment Status Page

The Modified By cell reads Clindoc when a patient assessment was generated by the interface.

The page displays the Assessment Status abbreviations: A (Audit), C (Complete), D (Deleted), and I (Incomplete) based on the outcomes received and assessed at pre-set times from the interface. If the Status cell is blank, Staff Manager did not receive or save any assessments for that patient. You should contact Cerner Clairvia Support for more information about the number of outcomes needed to generate complete patient assessments via the interface.

The Patient Acuity Assessment History Page

When Staff Manager receives an assessment from a clinical documentation interface, the Modified By cell reads Interface or Clindoc, depending on the batch configuration settings. Staff Manager also puts an interface icon beside the Acuity level.

If you want to change the clinical documentation settings, such as the Modified By label or pull forward time, you should contact your Cerner Clairvia Clinical Consultant.

When the interface sends new assessment data, Staff Manager generates a new patient assessment. It also pulls forward historical assessment findings documented in the patient’s current location for a specified number of hours in order to populate outcome assessments. This allows Staff Manager to calculate outcome Likert ratings and Acuity levels. You should contact Technical Support for more information about pull forward periods.

The Interface Manager

Interface Manager is a utility used to check interface activity and search patient clinical documentation received via flat file or Registration Import. Administrators interested in this tool should contact their Cerner Corporation Clinical Consultant or Client Advocate.

Finishing an Incomplete Assessment

Incomplete assessments are assessments where the original caregiver used the Save Finish Later option.

From the Acuity menu, select Patient Assessment. The Patient Acuity Assessment page opens.
Select a profile/location in the Navigation pane.
Select a patient's name from the Patient List.
Select the Likert rating that best matches the patient’s state for each of the incomplete outcomes. You can select only one Likert rating per outcome.
Click Save (Complete).

More Information on Incomplete Assessments

Incomplete assessments display the word Incomplete in red next to the Assessment Date. This is the date and time the previous user saved the assessment as incomplete.

If you do not want to complete the assessment, select the New button. Selecting New removes the former outcome selections, updates the Assessment Date to the current date and time, and prepares the page for the new assessment.

Another way to finish incomplete assessments is available from the Patient Assessment History page.

From the Acuity menu, select Patient Assessment History. The Patient Acuity Assessment History page opens.
Click the Edit icon beside an incomplete assessment. The Patient Acuity Assessment page opens.
Proceed as in Finishing Incomplete Assessments above.

Printing a Single Assessment

You must have Adobe Acrobat Reader version 7.0 or later installed in order to print Patient Assessments.

You can print patient assessments from the Patient Acuity Assessment page by clicking the Printable View icon. This opens the patient’s assessment as a PDF file entitled Patient Assessment Report. Once printed, you can sign the report in the space provided at the bottom of the page.

You can include a printed copy of the Patient Assessment Report with each patient’s paper chart or use it as a worksheet to monitor or re-assess a patient’s status for later entry into Staff Manager.

You can also print patient assessments using the Assessment History tab of the Patient Encounter Information window.

Printing Multiple Assessments

You must have Adobe Acrobat Reader version 7.0 or later installed in order to print Patient Assessments.

From the Acuity menu, select Assessment Status. This opens the Patient Acuity Assessment Status page.
Select the check box in the patient row or rows. Select the All check box at the top of the column to select all patients.
Click the Print button above the All check box. The selected patient assessment or assessments opens as a PDF file.
Click the Adobe PDF Printer icon.

To print the patient acuity assessment status chart itself, click the Printable View icon, then click the Adobe PDF Printer icon.

You can also print patient assessments using the Assessment History tab of the Patient Encounter Information window.