Recording Assessment EHR Information
- Click a patient in the EHR status window and click “View Exam”
- Click the Assessment tab
- Record a diagnosis by clicking the appropriate body area on the back or the front of the body diagram, select the diagnosis from the list in the box labeled “Available Diagnosis” and click the “add diagnosis” button. The selected diagnosis will appear in the window “Selected Diagnosis”
- Remove a diagnosis by clicking the diagnosis in the “selected diagnosis” window and click the “remove diagnosis” button.
- Record the phase of care by clicking on the drop-down menu labeled “phase of care” and select the appropriate phase in the list.
- Record the prognosis of care by clicking on the drop-down menu labeled “prognosis” and select the appropriate prognosis in the list.
- Enter comments and notes by clicking on the button “New Comment” and type the information into the pop-up window. Click “OK” when done.