Completing an ePCR - General Assessment

Completing an ePCR - General Assessment

Purpose

  1. To explain how to complete the General Assessment section of Assessment in ePCR.

Related Articles

  1. Completing an ePCR - 1. Response
  2. Completing an ePCR - 2. Information
  3. Completing an ePCR - 3. Assessment
  4. Completing an ePCR - General Assessment (This Article)
  5. Completing an ePCR - 4. Vital Signs
  6. Completing an ePCR - 5. Treatments
  7. Completing an ePCR - 6. Billing, Outcomes & External Reporting
  8. Completing an ePCR - 7. Disposition & EMS Narrative
  9. Completing an ePCR - 8. Signatures

Video



Directions


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.


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.


Click on Save.



6. Use the trash can icon to delete body system assessment findings if necessary.


Use the trach 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.


Click on Save.



9. Click on Copy to copy all findings from the most recent assessment.


Click on Copy to copy all findings from the most recent assessment.




    • Related Articles

    • Completing an ePCR - 2. Information

      Purpose To explain how to complete the Information section of an ePCR. Related Articles Completing an ePCR - 1. Response Completing an ePCR - 2. Information (This Article) Completing an ePCR - 3. Assessment Completing an ePCR - General Assessment ...

    • Completing an ePCR - 1. Response

      Purpose To explain how to complete the Response section of an ePCR. Related Articles Completing an ePCR - 1. Response (This Article) Completing an ePCR - 2. Information Completing an ePCR - 3. Assessment Completing an ePCR - General Assessment ...

    • Completing an ePCR - 3. Assessment

      Purpose To explain how to complete the Assessment section of an ePCR. Related Articles Completing an ePCR - 1. Response Completing an ePCR - 2. Information Completing an ePCR - 3. Assessment (This Article) Completing an ePCR - General Assessment ...

    • Completing an ePCR - 5. Treatments

      Purpose To explain how to complete the Treatments section of an ePCR. Related Articles Completing an ePCR - 1. Response Completing an ePCR - 2. Information Completing an ePCR - 3. Assessment Completing an ePCR - General Assessment Completing an ePCR ...

    • Completing an ePCR - 7. Disposition & EMS Narrative

      Purpose To explain how to complete the Disposition & EMS Narrative section of an ePCR. Related Articles Completing an ePCR - 1. Response Completing an ePCR - 2. Information Completing an ePCR - 3. Assessment Completing an ePCR - General Assessment ...