Hands On Assessment Building Exercise

Purpose: To help you become familiar with maneuvering around in the various dictionaries you will be using to edit and create your assessments.

Goals:

A. Creating New Group Responses

B. Creating New Queries

C. Creating a New Instance Type

D. Placing Queries and the Instance Type on a New Assessment

E. Attach the New Assessment to a New Intervention

F. Document on the Assessment

G. Review the data in the EMR.

NOTE: Please follow this step by step, and make sure you are in the correct Dictionary at all times.

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A. Create New Group Responses

  1. From the Desktop Menu click on Clinical, >Dictionaries, >Documents, >Group Response. The Group Response Dictionary should now be on the screen.
  1. Select New on the toolbar to the right. You are now ready to create a new Group Response.
  1. In the Mnemonic field, enter in the mnemonic this way: SO1.XXX (anywhere you see XXX in this document, please type in the numbers on the card you were given) and then hit the <--| Enter key. You are not copying from an existing Group Response, so skip the Copy From field. Write down your Group Response mnemonic: ______.
  1. Yes will default into the Active field. Hit the <--| Enter key.
  1. In the Name field enter Sputum Color for the topic of this group response, then hit the <--| Enter key.
  1. At the Maximum Element Length field, enter the number 10 if it does not default in. Hit the <--| Enter key.
  1. In the Element Mnemonic field enter in the number 1 and hit the <--| Enter key. In the Element Name field, enter in the word Clear and hit the <--| Enter key. In the Rank field, enter in the number 1 and hit the <--| Enter key five times to get the cursor back to the Element Mnemonic field, skipping through the Value field, the Normal field, the Mnemonic field for E&M Coding Bullet Name section, and the Document Comment Text field.
  1. Continue to enter in the following responses for Sputum Color:

Element Mnemonic Element Name Rank

2White2

3Creamy3

4Yellow4

5Green5

6Gray6

7Tan7

8Rust8

9Brown9

10Red10

  1. When you have finished entering in these responses, click on the Save button in the lower right hand corner of the Footer region.
  2. Create a second Group Response. In the Mnemonic field, enter in the mnemonic this way: SO2.XXX, then hit the <--| Enter key. You are not copying from an existing Group Response, so skip the Copy From field. Write down your second Group Response mnemonic: ______.
  1. Yes will default into the Active field. Hit the <--| Enter key.
  1. In the Name field enter Sputum Consistency for the name of the topic, then hit the <--| Enter key.
  1. At the Maximum Element Length field, enter in 10 if it does not default in. Hit the <--| Enter key.
  1. Enter in the following responses for Sputum Consistency:

Element Mnemonic Element Name Rank

1Thin1

2Thick2

3Tenacious3

4Frothy4

5Mucoid5

6Mucoid Plug6

7Clots7

  1. Now click on the Save button in the lower right hand corner of the footer region. Select View on the side toolbar, and confirm your two new entries are in the lookup by selecting SO1.XXX (your number) then F9, and SO2.XXX (your number) then F9.
  1. Now click on the X in the top right hand corner of the screen to exit out of the Group Response Dictionary.

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B. Create New Queries

  1. From the Documents menu that is opened, click on >Query. The Query Dictionary should now be on the screen.
  1. Select New on the toolbar to the right. You are now ready to create a new Query.
  1. In the Mnemonic field, enter in the mnemonic this way: SO1.XXX, then hit the <--| Enter key. Write down your Query mnemonic: ______.
  1. Yes, will default into the Active field. Hit the <--| Enter key.
  1. In the Text field, enter the query text of: Sputum Color, then hit the <--| Enter key.
  1. At the Type field, click on the down arrow (black triangle) at the far right hand side of the field. From the drop down listing the query types, click on Group. The Multiple field will default to No. Hit the <--| Enter key twice. This will bring the cursor to the Group Response field.
  1. Enter the mnemonic of the Group Response you just created for Sputum Color (SO1.XXX) and hit the <--| Enter key.
  1. In the Translate section at the bottom of the screen, click on the Data Records button. Click on the Save button in the lower right hand corner of the Footer Region to save your query.
  1. In the Mnemonic field, enter in the mnemonic SO2.XXX for the second query. Hit the <--| Enter key.

Write down your second Query mnemonic ______.

  1. Yes will default into the Active field. Hit the <--| Enter key.
  1. In the Text field, enter Sputum Consistency for this query, then hit the <--| Enter key.
  1. At the Type field click on the down arrow (black triangle) at the far right hand side of the field. From the drop down listing the query types, click on Group. The Multiple field will default to No. Type in a Y in the Multiple field as this query will be a Group Multiple type query. Hit the <--| Enter key twice. This will bring the cursor to the Group Response field.
  1. Enter the mnemonic of the Group Response you just created for Sputum Consistency (SO2.XXX) and hit the <--| Enter key.
  1. In the Translate section at the bottom of the screen, the Data Records will still be selected as a carry over from the previous query entry, so click the Save button in the lower right corner to save your query.
  1. In the Mnemonic field, enter in the mnemonic SO3.XXX for the third query. Hit the <--| Enter key. Write down your third Query mnemonic ______.
  1. Yes, will default. Hit the <--| Enter key.
  1. In the Text field, enter IncentiveSpirometry Number of Repetitions, then hit the <--| Enter key.
  1. At the Type field, this time type in an N and hit the <--| Enter key. The query type of Number will default into the field. Hit the <--| Enter key once. This will bring the cursor to the Length field.
  1. In the Length field, enter in the largest number of characters your response will have. Remember that the system counts a comma as a character. In this case, enter in the number 2. The Data Records button should still be selected from the previous query.
  1. Now click on the Parameters button at the top of the screen. Click on the Units field and enter the word repetitions. Click on the Save button in the lower right corner.
  1. In the Mnemonic field, enter in the mnemonic SO4.XXX. Hit the <--| Enter key. Write down your fourth Query mnemonic ______.
  1. Yes will default into the Active field. Hit the <--| Enter key.
  1. In the Text field, enter Incentive Spirometry Volume Amount, then hit the <--| Enter key.
  1. At the Type field, this time type in Q and hit the <--| Enter key. The query type of Quantity will default into the field. Hit the <--| Enter key once. This will bring the cursor to the Length field.
  1. In the Length field enter in the largest number of characters your response will have. Remember that the system counts both commas and decimal points as characters. In this case, enter 8. (If a care provider documents 1250.25 the system will display this as 1,250.25 which is 8 characters in length.) Hit the <--| Enter key. The cursor advances to the Decimal Precision field.
  1. In the Decimal Precision field, enter the number of characters you want to appear to the right of the decimal place. In this case, enter the number 2. Data Records should still be selected from the previous query.
  1. Click on Parameters at the top of the screen. Click on the Units field and enter the abbreviation mls. Click on the Save button. Now, select View to confirm your four queries are listed in the lookup when you enter the mnemonics you just created. Then click on the X in the top right of the screen to exit the Query Dictionary.

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C. Create a New Instance Type

  1. From the Documents menu, click on >Instance Type. The Instance Type Dictionary should now be on the screen.
  1. Click on the New button on the toolbar to the right. You are now ready to create a new Instance.
  1. In the Mnemonic field, enter in the mnemonic SO1.XXX, then hit the <--| Enter key twice to bring the cursor to the Active field. You are not copying from an existing Instance Type, so skip the Copy From field. Write down your new Instance Type mnemonic ______.
  1. Yes will default into the Active Field. Hit the <--| Enter key.
  1. In the Question field enter in the description that will appear on the assessment where this Instance Type will be placed. In this case, enter the words Lung Location. Hit the <--| Enter key.
  1. In the Allow Ad lib Responses field enter N which will change to the word No after you hit the <--| Enter key. By entering N, a user can select only those entries listed and cannot free text a different response.
  1. The Special Type field is used only for documenting IV's, so hit the <--| Enter key again to bring the cursor to the Group Response field. Enter in PCS.LR and hit the <--| Enter key to bring the cursor to the Sort by field.
  1. In the Sort by field, click on the down arrow (black triangle) at the far right. Click on Rank from the drop down listing. You will be brought to the next line in the Group Response field.
  1. You are going to make a new Group Response to enter into the Instance Type Dictionary. To do this, you must bring up the Group Response Dictionary. Look at the Windows toolbar at the bottom of your computer screen. Click on the button that indicates the name of your facility. Doing this will bring up the main desktop. From the Documents menu, click on >Group Response. The Group Response Dictionary should now be on the screen.
  1. Click on the New button on the toolbar to the right. You are now ready to create a new Group Response.
  1. In the Mnemonic field, enter in the mnemonic SO3.XXX, then hit the <--| Enter key twice. You are not copying from an existing Group Response, so skip the Copy From field. Write down this third Group Response mnemonic ______.
  1. Yes will default into the Active field. Hit the <--| Enter key.
  1. In the Name field enter Lung Location as the topic of this group response, then hit the <--| Enter key.
  1. At the Maximum Element Length field, enter in 10 if it does not default in. Hit the <--| Enter key.
  1. Enter in the following responses for Lung Location:

Element Mnemonic Element Name Rank

1Upper1

2Lower2

3Middle3

4Bases4

5Throughout5

  1. Click on Save in the lower right hand corner, select View to confirm the entry is there by selecting SO3.XXX, then click on the X in the top right corner to exit out of the Group Response Dictionary.
  2. The main desktop may now be on the screen. You need to go back to the Instance Type Dictionary to complete your entry. Look once again at the Windows toolbar on the computer screen. Click on the button that indicates Instance Type Dictionary. The Instance Type Dictionary with the entry you had started should now be on the screen.
  1. In the Group Response field enter in the mnemonic of the group response you just created: SO3.XXX and hit the <--| Enter key. The words Lung Location will default into the field.
  1. In the Sort by field enter in the letter R and hit the <--| Enter key. The word Rank will default into the field.
  1. Preview the Instance Type by clicking on the Preview button in the Footer Region. Click on the OK button on the pop up box to close the preview box. Click on Save in the lower right corner.
  1. Select View to confirm your new Instance Type is there (SO1.XXX), then click on the X in the top right hand corner of the screen to exit out of the Instance Type Dictionary.

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D. Place Queries and the Instance Type on a New Assessment

  1. From the Documents menu that is opened on the screen, click on >Documentation Section.
  1. Click on the New button on the toolbar to the right. You are now ready to create a new Assessment.
  1. In the Mnemonic field, enter in the mnemonic SO.RESP.XXX, then hit the <--| Enter key twice. You are creating an entirely new assessment, not copying a previously created assessment. Write down the Assessment mnemonic ______.
  1. Yes will default into the Active field. Hit the <--| Enter key.
  1. In the Name field, enter Respiratory Assessment. This name appears on the documenting Flowsheet. Hit the <--| Enter key.
  1. Draft is the default response in the Status field. Keep your assessment in Draft status in TEST. When the Assessments in the Documentation Section Dictionary are moved to LIVE, they will be automatically changed to a Final status. Final status affects how assessments can be edited in the LIVE environment. Hit the <--| Enter key.
  1. In the Use for Documents field enter in N for No and hit the <--| Enter key. Enter in Y for Yes in the Use for Assessments field. Hit the <--| Enter key and you will be brought to the Recall field.
  1. In the Recall field, Manual will automatically default into the field. Hit the <--| Enter key to be brought to the Question Sets screen.
  1. Enter in the following in the fields in the Question Sets section. Remember to hit the <--| Enter key after each entry.

LabelActiveRepeat?Instance Type Start Expanded? Recall Mode

Respirations Y (leave blank) (leave blank) Y (leave blank)

  1. After hitting the <--| Enter key at the Recall Mode field, the cursor will move down to the Questions section at the Type Prompt. Either click on the down arrow (black triangle) to the right of the field and select Query from the drop down listing or enter in a Q and Query will default in when you hit the <--| Enter key. The cursor now appears in the Label field.
  1. The first query to place on the assessment is an existing query, the Respiratory Rate query. Type in VS.RESP, and hit the <--| Enter key. This will bring the query onto the Assessment. Yes defaults in the Active field. You are not entering any text in the Override Label field for this query. Hit <--| Enter key twice to return the cursor back to the next blank line in the Type field. You've now entered an existing query onto a new assessment.
  1. Just enter Q and Query will default in when you hit the <--| Enter key. Type in the mnemonic RESP.POSAT in the Label field and hit the <--| Enter key. Yes defaults in the Active field. Hit the <--| Enter key. In the Override Label field type in Pulse Oximetry. Hit the <--| Enter key twice to get to a blank line of the Label field in the Question Sets section.
  1. Enter in the following in the fields in the Question Sets section. Remember to hit the <--| Enter key after each entry.

LabelActiveRepeat?Instance Type Start Expanded? Recall Mode

Sputum Y (leave blank) (leave blank) Y (leave blank)

  1. After hitting the <--| Enter key at the Recall Mode field, the cursor will move down to the Questions section at the Type Prompt. Enter Q and Query will default in when you hit the <--| Enter key. The cursor now appears in the Label field.
  1. Enter in the two new Sputum queries that you just created (SO1.XXX and SO2.XXX) for this Question Set. Make sure to have Active = Yes. Hit the <--| Enter key four times to get to the Label field (or just click on the next blank Label field).
  1. Enter in the following in the fields in the Question Sets section. Remember to hit the <--| Enter key after each entry.

Label Active Repeat?Instance Type Start Expanded?Recall Mode

Auscultation Y Y SO1.XXX Y (leave blank)

  1. After hitting the <--| Enter key at the Recall Mode field, the cursor will move down to the Questions section at the Type Prompt. Enter Q and Query will default in when you hit the <--| Enter key. The cursor now appears in the Label field.
  1. Enter in the following queries for this Question Set:

RESP.PHASE with the text of Respiratory Phase entered into the Override Label field,