The Initial Nursing Assessment or Start of Care (SOC) can be accessed in two ways:
1) From the task list on the Patient Dashboard. An Initial Nursing Assessment task is automatically generated for a new admission.
2) From the Things You Can Do Menu > Create New Documentation > Initial Nursing Assessment
Completing the Form
|Enter the date of the visit, start time, end time and mileage.|
|Link to Visit will become available when at least the visit date is entered. This option enables you to link this visit to an existing visit on the calendar or create a new visit.|
|Completing sections - enter the information in various methods|
- free text
- drop down selection
- multi-select boxes
- single select radial
|All the following sections have the option to create a Care Plan at the bottom of the section.|
|The Pain Assessment section has an option to have a Followup reminder. |
|Vital signs are located in the Physical Assessment section|
|A Self-Care Deficit care plans can be created in this section|
Click Preview when done to sign the document. The document can be partially completed, in which case it will be available in Documents > Private.