Continued Care: Collecting Integrated Assessments

Integrated Assessments are critical for monitoring a patient’s overall health, tracking progress, and identifying potential complications. While vital signs, height, and weight are typically recorded during intake, ongoing assessments may be conducted based on the patient’s stability and the Level of Care (LOC) they are entering. These assessments enable providers to develop personalized treatment plans and ensure patient safety throughout treatment. 

Required Permissions: Nurse, Doctor, Tech, Record Admins, and Super Admins.

Best Practice Workflow Video

Types of Integrated Assessments in Kipu EMR

Integrated Assessments are available in the Doctor's Orders tab, Med Log tab, Rounds Intervals, and any form containing the appropriate evaluation field type.

• Vital Signs: Records the patient’s vital signs, including blood pressure, temperature, pulse, respiration, and O2 saturation, in the Doctor's Orders tab, Med Log tab, Rounds Intervals, or any form containing the patient.vital_signs evaluation field.
  

  • Best Practice: Enable Abnormal Vital Sign Warnings to automatically highlight abnormal vital signs results.

• Orthostatic Vital Signs: Records the patient’s blood pressure and heart rate in sitting, standing, or lying down positions.
  
• Glucose Monitoring Log: Tracks the patient’s glucose readings, including the type of check and interventions in the Doctor's Orders tab, Med Log tab, Rounds Intervals, or any form containing the patient.glucose_log evaluation field.
  
• Height and Weight: Records the patient’s current height and weight in the Doctor's Orders tab, Med Log tab, Rounds Intervals, or any form containing the patient.height_weight evaluation field.

  • Best Practice: You can record and track the patient’s Target Body Weight (TBW). Add the TBW feature to the appropriate user profiles so that they can manage and edit this field. 

• CIWA-Ar: A 10-question assessment for monitoring alcohol withdrawal symptoms, scoring patients from 0 to 67.
• CIWA-B: A 20-question assessment for benzodiazepine withdrawal symptoms, scoring patients from 0 to 80.
• COWS: An 11-question assessment for opioid withdrawal symptoms, scoring patients from 0 to 48.
  

Best Practices: Use notifications for abnormal CIWA/COWS scores or vital sign readings to ensure appropriate staff members are alerted promptly to provide the best possible patient care. 

Best Practice Workflow Steps

Let's review the Kipu EMR best practice workflows to prepare for integrated assessment collection.

1. Provider evaluates the patient’s condition and determines if recurring integrated assessments are necessary.
2. Click on Action Order from Quick Orders in the Doctor’s Orders tab to schedule specific integrated assessments at defined intervals. Action orders are used for non-medication orders, such as checking vital signs, check CIWA, or performing specific tasks like changing bandages or linens.

   • Best Practice: Providers should order recurring integrated assessments using action orders, because they prompt users to collect the necessary data in the MAR/Med Log tab. Action orders can be incorporated into protocols, which are pre-built lists of frequently used medications and action orders created to streamline workflows and improve efficiency (e.g., taking vital signs before administering or observing medications). 

3. The Action Order appears in the MAR/Med Log tab at the scheduled interval and on the Dashboard Actions tab.
   
   • Select Yes next to the action order interval in the MAR/Med Log when an assessment is completed, enter a comment, and click Save status.
     
4. Medical staff collect the assessment data and log the results of the specified assessment(s).

   • Important: Assessments can be documented at the top of the MAR/Med Log, on the Doctor's Orders tab, with Rounds Intervals, or in any form containing the appropriate evaluation field type. Providers should periodically reassess and modify action orders as needed. Changes may include reducing the frequency of assessments, discontinuing specific assessments, or discontinuing all assessments entirely.

By adhering to these guidelines, facilities can ensure accurate monitoring, effective communication, and optimal patient care.