Integrated Assessments Setup

Easily record key patient measurements like vital signs, orthostatic vital signs, weight, height, glucose, CIWA-Ar, CIWA-B, and COWS. These integrated assessments can recorded under the Doctor's Orders tab, Med Log tab, and/or any Evaluation form configured with the appropriate field. 

This article focuses on enabling assessments in the Instance settings and adding the related fields to Evaluations. 

Enable Integrated Assessments

Each integrated assessment can be enabled or disabled individually by Super Admins within your Instance settings. 

1. To begin, click on your initials and then click Settings. 
   
2. Then click the Instance tab.

3. In the System options, locate the section titled Show in MARs & Doctor's Orders?
4. Check each measurement that you want to track in your facility.
5. If your organization is using vitals, you can configure the system to provide a warning when an abnormal sign is entered by checking Enable Abnormal Vital Sign Warnings. This setting will automatically highlight the abnormal result in red when entered.
6. You can set the desired normal ranges using the From and To boxes or use the standard default ranges provided.
7. If you'd like to record and track a patient's target weight, check the Use Target Body Weight box. Be sure that the necessary users have the Manage Target Body Weight role enabled, otherwise they will be able to view but not edit target body weight.
8. Scroll to the end of the page and click on Submit.

Add Integrated Assessments to Evaluations

Super Admins or users with the Manage Templates (or Manage Templates - Consents and Evaluations) feature can create standalone evaluations to log integrated assessments or incorporate the integrated assessment field types into any existing evaluation. 

1. Navigate to Templates and open Evaluations.
2. Create a new evaluation or edit an existing evaluation.
3. To add a new field, click Add item under the Evaluation Items section.
4. Include any of the following integrated assessment fields using the Field type drop-down.
   • patient.ciwa_ar: Log the patient's CIWA-Ar.
   • patient.ciwa_ar_current: Displays the patient's most CIWA-Ar answers and score on file.
   • patient.ciwa_b: Log the patient's CIWA-B.
   • patient.ciwa_b_current: Shows the most recent CIWA-B answers and score on file.
   • patient.cows: Log the patient's COWS.
   • patient.cows_current: Displays the most recent COWS answers and score on file.
   • patient.glucose_log: Log glucose monitoring results. Tip: Forms with patient.glucose_log can be configured as a log, allowing multiple glucose entries to be added within the same form. Set form's Evaluation Content to Notes/Logs with the only item patient.glucose_log. Click here to learn more.
   • patient.height_weight: Log patient's weight and height. This field also automatically includes BMI and allows Target Body Weight to be recorded if that feature is enabled in the Instance settings.
   • patient.height_weight_current: Display the patient's most recent height/weight on the evaluation.
   • patient.orthostatic_vitals: Log patient blood pressure and heart rate in sitting, standing, or lying down positions.
   • patient.orthostatic_vital_signs_current: Display the patient's most recent orthostatic vitals on the evaluation.
   • patient.pain_scale: Display the patient scale option to record the patient's reported pain scale.
   • patient.pain_scale_current: Display the patient's most recent pain scale report on the evaluation.
   • patient.vital_signs: Log blood pressure, temperature, pulse, respiration, and O2 saturation.
   • patient.vital_signs_current: Display the patient's most recent Vital Signs on the evaluation.
5. Click Update to save. 

Evaluation Tips

• The Integrated Assessment fields can be incorporated in any form (e.g. Nursing Progress Note) or used as a standalone form with only one field for a recorded log (e.g. Clinical Institute Withdrawal Assessment of Alcohol Scale - CIWA-Ar).
• You can only use the same field once per evaluation form (e.g., once you add patient.vital_signs to an evaluation, you cannot add it again). However, you can combine any of the integrated assessment fields together or with any other field type.
• After the template has been created/updated, any user who has access to manage forms and whose function matches the form's signature requirements will be able to add the form and record the client's results.