Enter an Assessment
Assessments are an important part of resident care. RTasks offers customizable assessments and effective ways to manage assessments that assist in meeting regulatory requirements.
Users with Role 32 are able to document clinical Assessments. The ability to perform non-clinical assessments (leisure, dietary, and Bio/History) can be granted to non-nursing providers; contact ResiDex support staff for assistance in doing so.
Enter Assessments in RTasks:
From the Menu bar in RTasks, select Clinical > Assessments.
Select a Resident or Prospect and the Assessment Type you wish to enter. Discharged residents are visible here up to 3 months post-discharge. Note: If an assessment has been previously started and not marked complete, it will be listed as an 'open' assessment. Users can finish the open assessment and mark complete. Not all assessment options are available to perform until an open assessment is complete.
The Assessment Type menu may vary, based upon whether assessment customization has been done for your organization, and/or roles or permissions granted to you as a staff person. Assessment titles and Clinical Subsets can all be customized.
- The Pre-admission assessment is typically performed on Prospects
- The Admission assessment is performed once, on admission.
- The Clinical Update, the real 'work horse' of assessments, is used for all full clinical assessments after the Admission
- The Transfer and Discharge Assessments are typically very short and completed upon discharge
- Review Assessment Details serves as a 'back door' into any assessment item - allowing you to view and make minor changes without performing a complete assessment.
Once the Assessment type is selected, the user can enter the context of the assessment (done in person or remotely) and if a Clinical Update, the reason the assessment is being performed (e.g. 14-day or 90-day reassessment, Change of Condition, etc...)
The assessment history button will allow you to view a history of the completed assessments for that resident.
- The next assessment due date listed here can be edited (1)
- Each instance of an assessment can be reviewed
- An optional notes field in the assessment history will allow you to add a note regarding any circumstances surrounding that assessment. (2)
- The assessment can be printed (3)
- The person entering the assessment is able to delete an assessment that has been entered in error by clicking on the icon to the far right of that assessment (4)
- Click on the Assessment History button a second time to close the history view.
Performing the Assessment
Once an assessment is started, blue links (1) indicate assessment categories. Click on the category to view items and add or edit details to items in that category
- 'Counts' by each line item (2) will display how many topics in the categories have been or need to be completed.
- Not all items in each category are required to be addressed. Notifications will appear to the user if a required element is not addressed.
Add/Edit Assessment Details:
Click on a category link to see the evaluation options
- Click the select box to select or de-select an assessment option. Add Note or Edit Note buttons allow an optional Note (1)
- The date an item was selected and the name of the person who selected that item appears to the right of each item (2)
- An optional configuration allows users to add, view, and edit any services for the resident that relate to the category (3) (see below)
- Press Back to return to all assessment categories
Add Services During Assessment Entry
If assessment -> service links have been created, you will have the option of entering a service or services into the Resident's Service Plan while completing an assessment. This is how it will look:
- Begin entering an assessment as outlined above
- If an evaluation option is linked to services a "Show related services" option will appear
- When you click on the link, related services will be displayed
- To add a service, click on the "Add to schedule" option and to edit the service on the service plan click "Already on service plan"
- This is what displays on the "Already on service plan" screen
- Follow our detailed instructions on Editing a Resident's Service Plan
If the assessment option "Skin Diagram" is included as part of your assessment, users may click on the body diagram itself to show location, then add information about the skin concern in the corresponding field below and then click 'Save'.
Marking an Assessment Complete
Click 'Mark Assessment as Completed' to close the assessment. This applies the current date to the assessment and sends Care Plans to staff to review and acknowledge.
Enter the date of the next required assessment or click the 'Quick Select' button to choose an option. RTasks will calculate the due date for the next assessment. You can optionally enter a reason for that next assessment.
Users can be notified on the Log In Report of upcoming assessments.