The Nursing Assessment module enables nurses to document routine observations, focused clinical findings, risk screenings, comprehensive assessments, and ongoing patient monitoring throughout the patient's stay.
STEP 01 / 11Assessment CategoriesSelect the appropriate assessment category to begin documenting the patient's condition based on the clinical situation.STEP 02 / 11Daily LogsChoose a routine nursing documentation type, including Vital Signs, Intake & Output, Supply Orders, Care Plan, Nursing Progress Notes, SBAR Handoff, or Body Metrics.STEP 03 / 11Vital SignsRecord temperature, pulse, respirations, blood pressure, MAP, and body position. The system automatically identifies abnormal values for clinical review.STEP 04 / 11Intake & OutputDocument all fluid intake and output to monitor hydration status, fluid balance, and renal function.STEP 05 / 11Focus System AssessmentSelect the body system requiring evaluation and document focused assessment findings for targeted clinical care.STEP 06 / 11Mental Health AssessmentChoose a standardized mental health assessment to evaluate cognition, mood, anxiety, depression, suicide risk, and overall psychological status.STEP 07 / 11Risk AssessmentComplete validated screening tools to identify risks such as falls, pressure injuries, delirium, malnutrition, and cognitive impairment to support preventive care.STEP 08 / 11Comprehensive AssessmentPerform a complete nursing assessment, including functional status, head-to-toe examination, and comprehensive pain assessment.STEP 09 / 11Acute Illness AssessmentConduct a rapid assessment for patients with acute illness or sudden clinical deterioration to guide timely interventions.STEP 10 / 11Pediatric AssessmentPerform pediatric-specific assessments, including APGAR scoring, to evaluate newborn health immediately after delivery.STEP 11 / 11MonitoringDocument ongoing monitoring for wound care, ventilator management, seizure activity, infection surveillance, Glasgow Coma Scale, drains and tubes, and IV line or vascular access management.
