1. Under the "Assessment" group, click on Add.
2. Document the Assessment Date & Time by manual entry or click on the clock icon to document the current time.
3. Click on a body system to document assessment findings unique to the body system involved.
4. Document present signs & symptoms as well as applicable pertinent negatives.
5. Click on Save.
6. Use the trash can icon to delete body system assessment findings if necessary.
7. For lower acuity patients, the "No Abnormalities" toggle will document "normal" findings in all body systems.
8. Click on Save.
9. To default some assessments during a Cardiac Arrest, Toggle on the Cardiac Arrest assessment.
10. Click on Copy to copy all findings from the most recent assessment.