COMPLETE A RESIDENT ASSESSMENT
How To:
COMPLETE A RESIDENT ASSESSMENT.
Click on Resident Care –Current Resident.
Click on choose a resident (small arrow down on right hand side).
Choose a resident by name.
Once you have chosen your resident, their name and photo will appear on the screen.
Once you have chosen your resident, click on Assessment and Care Plan.
Choose the Domain you want to write the care plan in e.g., Cognition.
When a domain is chosen the Domain Screening Assessment will appear.
To add or edit information click on Update Assessment.
Having clicked update assessment, boxes in the assessment can be ticked.
Where text is required to be entered a text box will appear.
Check to ensure the date of assessment is correct as todays date will automatically appear.
Once the screening assessment is completed, the completion box should be ticked.
Once the screening assessment is completed, click on save when you have completed the screening assessment. If you forget to save the information, it will automatically save for you.
You can also access old / previously completed / archived screening assessments by clicking on View Archive Button.
Click on an archive record to view it.
The old / previously completed / archived screening assessment will appear. You can view it but you can’t edit it.
To leave the old / archived screening assessment click on close. This will bring you back to the previous page / current screening assessment.
Some Screening Assessments will provide a prompt when you tick a particular box.
These prompts are instructing you to complete a risk assessment or task.
Risk Assessments are found in the Assessment Tools button.
Generic Risk Assessment in risk assessment tools.
Don’t forget to click update risk assessment to allow entering text or editing.
Using a generic Risk Assessment
•A generic risk assessment is only used where another tool e.g. Waterlow, MUST, Stratify, etc. is not available (these tools are found in ‘Other Tools’).
•Examples of when a generic risk assessment may be required are as follows:
Choking
Absconsion
Violence & Aggression
Self harm
(this list is not exhaustive).
Enter the risk/hazard e.g., the behaviour the resident displays.
Enter who could be harmed e.g., resident, staff, visitors, other residents, etc.
Enter how they could be harmed e.g. Knocked down by a car, physically assaulted, etc.
Consequences
Negligible: Minimal injury requiring
no/minimal intervention or treatment.
Minor: Minor injury or illness requiring minor Intervention.
Moderate: Moderate injury requiring
professional intervention.
Major: Major injury leading to
long-term incapacity/ Disability.
Catastrophic: Incident leading to death. Multiple permanent injuries or irreversible health effects.
Likelihood
Rare: This will probably never happen/recur.
Unlikely: Do not expect it to happen/recur but it is possible it may do so.
Possible: Might happen or recur occasionally.
Likely: Will probably happen/recur, but it is not a persisting issue/
circumstances.
Almost Certain: Will undoubtedly
happen/recur, possibly frequently.
When you enter the Likelihood and Consequence into each text box a risk score will automatically be calculated.
The coloured boxes indicate the risk rating, that is:
Extreme, High, Moderate or low.
Don’t forget to check that the date of the assessment and date of review are correct.
In the text box, type in the control measures put into place to reduce the likelihood of the risk occurring.
To save the risk assessment, click on save. If you forget, it will be automatically saved for you.
Alternatively. Click on another button to redirect to another section e.g. screening assessment or care plan.
To exit the risk assessment and return to the previous page click close.
To access previously completed/ archived assessments, click on risk archive.
Choose the archived risk assessment you want to view and click on it.
You can view the previously completed/ archived assessment but you cannot edit it.
To return to the previous page / current risk assessment click on close.
To access additional assessment tool e.g., Water low, click on ‘Other Tools’.
Other Tools containing assessments for each domain e.g. falls risk assessment, MUST, Geriatric Depression Scale, MMSE, Abbey Pain Scale, etc.
Clicking on your chosen assessment tool will open it.
To complete the assessment, click on new to be able to activate it.
Don’t forget to check the date of assessment as todays date will automatically appear.
To save the completed assessment, just click close.
To access previous /archived assessments, just click on the chosen assessment.
You can view the previously completed/ archived assessment but you cannot edit it.
To exit back to the current assessment, click on close.
To exit the screening assessment, assessment tools or the entire domain, just click on close.