Entering observations

You can record observations about your patients. After you enter an observation, you can manage escalations.

Read more about managing escalations

Sometimes you might have to skip observations, for example, if the patient is unavailable.

Read about skipping observations

Entering observations on a mobile

  1. From your patient list, select a patient.

  2. From Obs & Assessments, select Obs.

  3. Select the observation model.

  4. Add entries.

    • Depending on the field, enter numeric values with the number pad, select options, or enter text.

    • Some fields allow you to choose the method best suited to the reading.

      Select More... and choose.

    • Mandatory fields are marked .

  5. To move to the next observation:

    • Select Next.

      Or

    • Select the observation name you want to record.

When you record blood pressure, the slash / between systolic and diastolic readings is added automatically. When you add a temperature, the decimal point is added automatically.

Observation values are configured to have a specific range of options. When you add a value that is outside of the specified range, E is displayed.

You can’t submit observations when E is shown. Select the observation and enter a value in range.

E is shown in the same place as any corresponding EWS Early Warning Score. A vital signs recording and scoring system used with adult patients. The scoring system is designed to identify and alert appropriate staff in the case of deteriorating patients.. Be aware that E looks similar to an observation with an EWS of 3, for example, 3.

Each observation has a range of values that are deemed acceptable. When you enter a value for an observation, if the value is outside the acceptable range, a pop-up message might appear. The pop-up message offers you advice on activities you might want to perform. These messages differ depending upon the observation model.

To view an out-of-range message alert:

  1. Add an observation.

  2. When out-of-range, the message appears. Select OK to close the pop-up.

You can change the values you have added before you submit.

  1. Select the observation you want to edit.

  2. Enter a new value.

You can’t edit observation values after they have been submitted.

  1. Complete a set of observations, including all mandatory observations.

    Mandatory fields are marked .

    Read more about entering observations

  2. Select Submit Obs: n, where n dictates an EWS Early Warning Score. A vital signs recording and scoring system used with adult patients. The scoring system is designed to identify and alert appropriate staff in the case of deteriorating patients..

Entering observations on a desktop

Not all forms have observations in them.

To enter a set of observations:

  1. From  Inpatients > Patient List > double-click on a patient's name > Patient Detail, select Case Notes.

  2. Choose a form that fits your workflow and contains an observation recording option.
    For example, Triage in the Emergency Department.

  3. Select the observation option.

  4. Add entries.

  5. Move to the next observation. You can:

    • Press Enter to move to the next observation.

    • Select an observation.

    • Press Tab to navigate through the observations in sequence.

Some observation values are numeric, such as respiratory rate.

Enter numbers with the number pad.

You must manually add a slash / between systolic and diastolic readings for blood pressure.

You must manually add the decimal point when recording temperature.

Some observation values are configured with a list of options to choose when you select the observation. For example, oxygen device.

Choose an option.

Some observations are configured with a numerical field and a list, allowing you to either record a number, or choose from a list of options.

Press Ctrl + O keys and choose an alternate value.

Observation values are configured to have a specific range of options. When you choose an option that is outside of the specified range, the observation is highlighted in red.

You can't submit observations that are highlighted in red. Select the observation and enter a value in range.

You can change the values you have added before you submit.

  1. Select the observation you want to edit.

  2. Enter a new value.

  1. Complete a set of observations, including all mandatory fields.

    Mandatory fields are marked .

  2. Select Next.

Each observation has a range of values that are considered acceptable. If an observation value is outside the acceptable range, an alert appears on Alerts and Escalations. The alert messages differ depending upon the observation model.

Alerts and Escalations appears after you submit an observation.

Read more about submitting an observation

Read more about alerts and escalations

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