Purpose: To see if the patient has body parts that are physically harmed.
Scenario: A patient was involved in an accident and you want to capture information on body parts that got hurt.
Key terms:
Normal - the body part is functioning well without any harm.
Abnormal - the body part is not functioning well and showing signs of physial harm.
Watch video:
Follow the steps in order to record patient physical assessment:
Log in EHR app. Click here to see how to log in.
Before you start anything you need to do a Full Sync so that all records are updated. Click here to see how to perform a full synch.
Click on 'All Admissions'.
You can use the search bar to search for the preferred patient or scroll down till you find the name. After you found the patient click on the name to see all information concerning that patient.
Click on 'Assessments'.
Click on 'Physical Assessment' to add your assessment for that day.
After assessing the patient select whether the the body part is Normal or Abnormal and add notes on each and every assessment if necessary.
If there are any Key Notes on the assessment that need to be added, click on the pencil icon.