Entering observations for outpatients

1. Select Outpatient.

   • On iOS, you might need to select More to see Outpatient.

   • On Android, select  > Outpatients.

2. Choose a clinic and a day to view.

   Read more about viewing a list of appointments

3. Select the patient's appointment.

   Read about patient records for outpatients

4. From Obs & Assessments, select Obs > Additional Charts.

5. Select the additional chart.

   You can search for an additional chart.

   Read about additional charts

6. 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 .

   • If you enter a value outside the configured range, E appears. Select the observation and enter a value in range.

     Read more about errors

   • If you enter a value that is outside the acceptable range, a pop-up message might appear offering you advice.

     Read more about out-of-range information alerts.

7. To move to the next observation:

   • Select Next.

     Or

   • Select the observation name you want to record.

When you record blood pressure for non-pregnant and non-postnatal patients, the slash / between systolic and diastolic readings is added automatically. When you record blood pressure for pregnant and postnatal patients, systolic and diastolic readings are on separate lines.

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.

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 on the additional chart

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:.

3. Select Background / History to enter any notes.

4. Select Submit Observation.

From  Outpatients > Patient Detail > Clinical > Observations > +, you can enter observations.

1. From  Outpatients > Clinic List > double-click on a patient's name > Patient Detail > Clinical, find Observations.

2. Select +.

   If there is no +, then you need to select the correct appointment.

   Read about selecting the correct episode of care and appointment

3. Select the additional chart.

4. Add entries.

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

     Read more about entering numeric values

     Read more about selecting observations from a list

     Read more about selecting more options

   • Mandatory fields are marked .

   • If you enter a value outside the configured range, the observation is highlighted red. Select the observation and enter a value in range.

     Read more about errors

   • When a value has an associated 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., the EWS is shown on the left.

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.

6. Select Next to submit the observations.

   Read more about submitting observations

Some observation values are numeric, for example, height.

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, the observation 'Oxygen Device' might have the options 'Air', 'Venturi Mask', and 'Hudson Mask'.

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 .

   Read more about entering observations

2. Select Next.

   Alerts and Escalations is shown.

3. Check any out-of-range information alerts.

   Read more about out-of-range alerts

4. Add any notes.

   Read more about adding notes

5. Select Submit.

Each observation has a range of values that are considered within tolerance. If an observation value is outside this range, an alert appears on Alerts and Escalations. The alert messages differ depending on the additional chart.

From Alerts and Escalations, you can add notes to your observations. These notes are added to the observation chart.

1. From Nursing Notes, select Add comment....

2. Enter a note.

   • Select Save to save the note.

   • Select Cancel to go back.