Entering observations for outpatients

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 +.

3. Select the observation model.

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 upon the observation model.

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.