This article explains how to capture clinical observations as part of an aged care client's record.
You can capture clinical observations for an aged care client within their client record as well as viewing a list of all observation types, so that you can understand what has been captured/observed for that client and when.
The functionality described in this article requires the activation of home care package (HCP) features in your production environment.
To capture observations:
- Navigate to the client contact record and click on the Clinical Observations tab.
- Any recent observations will be listed under the Last 5 Clinical Observations heading. To add a new observation, click the New button.
- On the New Observation form, select the type of observation you wish to record from the list. Then click the Next button.
- In the Observation Date/Time fields, click and select a date and time. The Client field should auto-populate.
- In the Observation section, you will see different fields depending on the type of observation. See the table below for a list of observation fields.
A red asterisk (*) indicates a mandatory field.
|Observation type||Observation fields|
|Blood Glucose||Millimoles per litre of blood (mmol/L)|
|Blood Pressure||Diastolic blood pressure (DBP), Systolic blood pressure (SBP), Beats per minute (BPM)|
|Bowel||Faeces Type, Amount, Description, Method|
|Fluid intake||Food/Drink Item, Amount Served, Amount (mls)|
|Food intake||Food/Drink Item, Amount Served|
|Pain||Pain Type, Pain Symptoms|
|Seizure||Duration, Type of seizure, Symptoms|
|Skin integrity Issue||Integrity Issues, Possible Cause, New Issue (yes/no/unsure), Location, Estimated Size|
|Urine||Amount, Urine Colour (Hydration rating), Method|
|Weight||Weight (kgs), Weight Change|
- Click the Save button, or Save & New if you want to add more observations.