Psychiatric Assessment

5. HIS - Health Information Systems > Nursing Review

How to access to Psychiatric Assessment?

  • To access to Psychiatric Assessment, click Nursing Review >> Psychiatric Assessment.

 

 

  • Or from Psychiatric Assessment menu >> Psychiatric Assessment

 

 

  • This is the overview of the Psychiatric Assessment. User can search for Patient Psychiatric Assessment Reports by dates. User can also add, view, void and print assessment.

 

 

  • To perform the search, do the following:
    • Set the dates range
    • Select the checkbox if user is performing search for selected patient only(refer to the patient selected in the patient queue)
    • Click search

 

 


How to Add Assessment?

  • To add assessment, right click and select Add Assessment

 

 

  • The (Psychiatric Assessment –new) window will pops out. There are total of 6 tabs (Admission Data, Demograhic Data, Genogram(family tree), Physical Assessment, Pattern of Daily Living, Mental State Assessment). Note that source of referral, escort officer and assessment officer are compulsory field to filled in.
  • Under Admission Data tab, the Name, NRIC and Inmate No will be display by default. User need to key in other necessary information in the fields(Referral, Set the arrival date and time, Escorted By, Psychiatric in charge, Set Psychiatrist Referral fax date and time, Drug Allergy if required, Psychiatric History, Significant Information, Forensic History). Move on to Demographic Data tab.

  • Under Demographic Data tab, key in the necessary information to the fields (Language/Dialect Spoken, Education Level, Occupation, Marital Status, Religion, Accommodation, Living Arrangement). Move on to Genogram (Family Tree) tab.

 

 

  • Under Genogram (Family Tree) tab, key in the necessary information to the fields (Medical History if any)
  • If Female Patient checkbox is selected, key in the extra information (Family Planning, Menstrual Cycle). Move on to Physical Assessment tab.

 

 

  • Under Physical Assessment tab, there is Part I and Part II.
  • For Part I, key in the necessary information to the fields (General Condition, Vision, Hearing, Mobility, and Medical Complaint).

 

 

  • For Part II, user can do/draw marking on the diagram provided.
  • Click  to change the cursor to draw
  • Click  to change the cursor to erase
  • Click  to choose the colors and use  to adjust the size of the drawing cursor
  • Click  to restore the diagram to default
  • Move to Pattern of Daily Living tab.

 

 

  • Under Pattern of Daily Living tab, key in the necessary information to the fields (Select required checkbox for (Appetite, key in Smoking, Alcohol, Substance Abuse, Sleep, Elimination: Bowel and Urinary, select the required checkbox for self-care ability)
  • Move on to Mental State Assessment tab

 

 

  • Under Mental State Assessment, there is Part I and Part II
  • For Part I, key in General Appearance, Select the required checkbox for Motor Activity, Speech, Orientation, Memory and also key in additional information in Patient appears.

 

  • For Part II, key in necessary information in the field (Mood, Suicidal/Homicidal Thoughts, Thought Process, Sensory Perception, Insight, the officer that assessed the patient and set the date.
  • Click Ok to save all information or click Cancel to close the Psychiatric Assessment window.

 

 

How to view Assessment?

  • To view assessment, select the specific assessment and click View Assessment
  • The psychiatric assessment window will pops out to allow user to read the information.

 

 

How to Void Assessment?

  • To void assessment, select the specific assessment and click Void Assessment
  • State reason for void and click Ok to void or click Cancel to abort voiding

 

 

  • To print the assessment, select the specific assessment and click Print Assessment

 

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