Patient Care Data Entry: Assessment Page

How to Use the Assessments Section

The Assessments section uses a visual grid interface with buttons for each body system or region.

Date/Time of Assessment - Optional (eExam.03)

The date and time when the assessment was performed
Located at the top of the assessments grid

All Normal Button

Marks all exam areas with a "Normal/Assessed" indication
Changes all boxes from blue to green to show completion
Applies to all pre-defined assessment areas at once

All Not Done Button

Marks all exam areas with a "Not Done" indication
Changes all boxes from blue to green to show completion
Applies to all pre-defined assessment areas at once

Individual Normal Buttons

Each assessment area has its own "Normal" button
Functions the same as "All Normal" but only for that specific area

Individual Not Done Buttons

Each assessment area has its own "Not Done" button
Functions the same as "All Not Done" but only for that specific area

Assessment Popup Windows

Clicking on any assessment area (Skin, Neuro, Mental Status, Head, Face, Neck, Eye, Back/Spine, Shoulder, Hip, Leg, Knee, Ankle, Foot, Arm, Elbow, Forearm, Wrist, Hand, Lungs, Chest, Heart, Abdomen, Pelvis/Genital) opens a popup window with checkboxes for specific findings.

Popup Window Features

Key Shortcuts at Top of Popup:

"A" Button - Marks all descriptions as "Assessed"
"NP" Button - Marks all descriptions as "Not Present" (Pertinent Negative)

Saving Assessments:

Click "Save then Close" to save your selections and close the popup window
All selections are optional and allow multiple entries
Comments can be added (will display on hard copy reports but won't be sent to state or billing)

Finding Locations

Some assessments require you to specify a finding location first. These include:

Abdomen (eExam.10) - General, Left Lower Quadrant, Left Upper Quadrant, Right Lower Quadrant, Right Upper Quadrant
Back/Spine (eExam.13) - Cervical, Lumbar, Sacrum/Coccyx, Thoracic
Extremities (eExam.15) - Shoulder, Hip, Leg, Knee, Ankle, Foot, Arm, Elbow, Forearm, Wrist, Hand (with Left/Right/Bilateral options)
Eye (eExam.17) - Left, Right, Bilateral
Lungs (eExam.22) - Left, Right, Bilateral
Chest (eExam.24) - Left/Right Anterior/Posterior, General Anterior/Posterior, Left/Right Side

Assessment Areas and Available Findings

Skin Assessment (eExam.04)

Clammy
Cold
Cyanotic
Diaphoretic
Dry
Flushed
Hot
Jaundiced
Lividity
Mottled
Normal
Not Done
Pale
Poor Turgor
Red (Erythematous)
Tenting
Warm
Capillary Nail Bed Refill less than 2 seconds
Capillary Nail Bed Refill 2-4 seconds
Capillary Nail Bed Refill more than 4 seconds

Neuro Assessment (eExam.20)

Abnormal Sensation
Ataxia
Decerebrate Posture
Decorticate Posture
Fasciculations
Flaccid
Muscle Rigidity
Normal
Not Done
Paralysis
Posturing
Status Seizure
Other Seizures
Tremors
Weakness

Mental Status Assessment (eExam.19)

Alert
Altered mental status, unspecified
Confused
Developmentally Impaired
Disorientation, unspecified
Lethargic
Normal
Not Done
Oriented to Events
Oriented to Person
Oriented to Place
Oriented to Time
Pharmacologically Paralyzed
Pharmacologically Sedated
Psychologically Impaired
Slowness and poor responsiveness
State of emotional shock and stress, unspecified
Strange and inexplicable behavior
Uncooperative
Unresponsive
Unspecified coma

Head Assessment (eExam.05)

Abrasion
Avulsion
Battle Sign
Bleeding Controlled
Bleeding Uncontrolled
Burn-Blistering
Burn-Charring
Burn-Redness
Burn-White/Waxy
Cerebrospinal Fluid
Contusion
Crush Injury
Deformity
Foreign Body
Gunshot Wound
Implanted Device
Laceration
Normal
Not Done
Pain
Puncture/Stab Wound
Raccoon's Eyes
Swelling
Tenderness

Face Assessment (eExam.06)

Abrasion
Avulsion
Bleeding Controlled
Bleeding Uncontrolled
Burn-Blistering
Burn-Charring
Burn-Redness
Burn-White/Waxy
Contusion
Crush Injury
Deformity
Gunshot Wound
Laceration
Normal
Not Done
Pain
Puncture/Stab Wound
Swelling
Tenderness

Neck Assessment (eExam.07)

Abrasion
Avulsion
Bleeding Controlled
Bleeding Uncontrolled
Burn-Blistering
Burn-Charring
Burn-Redness
Burn-White/Waxy
Contusion
Crush Injury
Deformity
Distended Neck Veins
Foreign Body
Gunshot Wound
Implanted Device
Laceration
Normal
Not Done
Pain
Puncture/Stab Wound
Stoma
Swelling
Tenderness
Tracheal Deviation

Eye Assessment (eExam.18)

Abnormal Eye Movement
Bleeding Controlled
Bleeding Uncontrolled
Burn-Blistering
Burn-Charring
Burn-Redness
Burn-White/Waxy
Contacts
Contusion
Dilated
Foreign Body
Glass Eye
Gunshot Wound
Laceration
Normal
Not Done
Periorbital Ecchymosis
Pin Point
Pupil Inequality
Pupil Reactivity-Normal
Pupil Reactivity-Sluggish
Pupil Reactivity-Unresponsive
Puncture/Stab Wound
Swelling
Tenderness

Back/Spine Assessment (eExam.14)

Abrasion
Avulsion
Bleeding Controlled
Bleeding Uncontrolled
Burn-Blistering
Burn-Charring
Burn-Redness
Burn-White/Waxy
Contusion
Crush Injury
Deformity
Gunshot Wound
Laceration
Normal
Not Done
Pain
Puncture/Stab Wound
Swelling
Tenderness

Extremities Assessment (eExam.16)

Abrasion
Avulsion
Bleeding Controlled
Bleeding Uncontrolled
Burn-Blistering
Burn-Charring
Burn-Redness
Burn-White/Waxy
Contusion
Cool/Cold to Touch
Crush Injury
Cyanosis
Decreased Range of Motion
Deformity
Erythema/Flushing
Foreign Body
Gunshot Wound
Hot/Warm to Touch
Implanted Device
Laceration
Lividity
Mottled
Normal
Not Done
Pain
Puncture/Stab Wound
Swelling
Tenderness

Lungs Assessment (eExam.23)

Breath Sounds-Absent
Breath Sounds-Decreased
Breath Sounds-Equal
Breath Sounds-Normal
Foreign Body
Increased Respiratory Effort
Normal
Not Done
Pain
Pain with Inspiration/Expiration
Rales
Rhonchi
Rhonchi/Wheezing
Stridor
Wheezing-Expiratory
Wheezing-Inspiratory

Chest Assessment (eExam.25)

Abrasion
Avulsion
Accessory Muscles Used with Breathing
Bleeding Controlled
Bleeding Uncontrolled
Burn-Blistering
Burn-Charring
Burn-Redness
Burn-White/Waxy
Contusion
Crush Injury
Deformity
Flail Segment
Gunshot Wound
Implanted Device
Laceration
Normal
Not Done
Pain
Pain with Inspiration/Expiration
Puncture/Stab Wound
Retraction
Swelling
Tenderness
Tenderness-General

Heart Assessment (eExam.09)

Heart Rate-Regular
Heart Rate-Irregular
Heart Rate-Tachycardic
Heart Rate-Bradycardic
Normal
Not Done
Pacemaker
Murmur

Abdomen Assessment (eExam.11)

Abrasion
Avulsion
Bleeding Controlled
Bleeding Uncontrolled
Burn-Blistering
Burn-Charring
Burn-Redness
Burn-White/Waxy
Contusion
Crush Injury
Deformity
Distended
Evisceration
Firm
Gunshot Wound
Guarding
Implanted Device
Laceration
Mass
Normal
Not Done
Pain
Pulsating Mass
Puncture/Stab Wound
Rebound Tenderness
Rigid
Soft
Stoma
Swelling
Tenderness

Pelvis/Genital Assessment (eExam.12)

Abrasion
Avulsion
Bleeding Controlled
Bleeding Uncontrolled
Burn-Blistering
Burn-Charring
Burn-Redness
Burn-White/Waxy
Contusion
Crush Injury
Crowning
Deformity
Distended Bladder
Foreign Body
Gunshot Wound
Implanted Device
Laceration
Normal
Not Done
Pain
Priapism
Puncture/Stab Wound
Swelling
Tenderness

NEMSIS v3.5.1 Changes

Chest/Lung Assessment Split

Previously combined, now separate assessments
Chest Assessment (eExam.24-25) focuses on chest wall findings
Lung Assessment (eExam.22-23) focuses on breath sounds and respiratory findings

Extremity Finding Location Updates

"Forearm-Left" updated to "Arm-Lower-Left"
"Forearm-Right" updated to "Arm-Lower-Right"
New whole limb options: Whole Arm and Hand, Whole Hand, Whole Leg, Whole Foot (Left/Right for each)

Eye Assessment Additions

Dilated
Pin Point

Mental Status Assessment Additions

Altered mental status, unspecified
Developmentally Impaired
Disorientation, unspecified
Pharmacologically Paralyzed
Pharmacologically Sedated (replaces "Pharmacologically Sedated/Paralyzed")
Psychologically Impaired
Slowness and poor responsiveness
State of emotional shock and stress, unspecified
Strange and inexplicable behavior
Uncooperative
Unspecified coma

Neurological Assessment Updates

Status Seizure (new)
Other Seizures (new)
"Seizures" removed (replaced by Status Seizure and Other Seizures)

Patient Care Data Entry: Assessment Page > Exams Tab

This section documents physical assessment findings for the patient using AIM's Assessment Section.