Charting a Nursing Assessment

To open a form: From PAL:  Click on patient’s name.

 Verify that the correct patient was selected.  Click the Ad Hoc Charting button.

To chart an assessment:  The Ad Hoc Charting window displays the list of forms.  Click NURSING ASSESSMENT.

 Click the Chart button on the bottom of the window.  The Nursing Assessment Launcher displays. The Launcher  The launcher allows the user to chart a full or partial assessment by selecting one, several or all of the body systems.  Other specific assessments like ADL’s, Pain, etc. can be selected.  The Navigator on the left side of the screen allows moving between opened systems and the launcher. A white Navigator bar indicates the current page the user has open.  Reference Text is available in some fields. Right-click to find Reference Text option  Right Click and Clear any opened systems or pages where there is no documentation. (Mistakenly opened). Patient Norms Not Subject to Change  Chart patient conditions that are not going to change during the course of the hospitalization. Examples: HOH, blindness, prosthesis Charting an assessment:  The Performed on field defaults to the current date and time (through Ad Hoc)  Change the date/time to reflect actual time of the assessment

 Click to select WDL or Variance of the assessed system.  For WDL definition right-click in field and select Reference Text.  If assessment is WDL, the system page will not open and charting is complete.  Variance will open the system page. Select only those variances that need to be charted. The user does not have to fill in every field.  Click the Return Arrow when charting completed on the system page.  Continue to open additional systems or assessment pages to chart as needed.  Click the system Navigator bar to reopen when making changes prior to signing.  Click the “Sign Charting” button on the toolbar when assessment completed.  PowerChart will not allow signing until required fields are completed

 Required fields are designated in yellow Viewing Assessment  View data in the Patient Assessment, Results Review, and Interactive View sections.

Assessment Page  A systems assessment page opens when a variance is selected.  Make selections in the desired fields.  Square buttons allow multiple choices in a field.  Right-click to add or delete a row in a grid.  Click in a cell to enter data in grid fields.  Click Return Arrow button to return to Launcher.

Focus Notes  Only one focus note can be done per Nursing Assessment form (use Ad Hoc for additional forms).  Focus field is required.  Use Long Focus Note for detailed documentation.

Charting errors  Correct charting errors on the Forms tab