MOSAIQ User's Guide - UCSF Radiation Oncology

Adding Assessments
CHAPTER 3: General Clinical Charting
Assessments can include configured drop-down items, checkboxes, and free text fields.
1. In the Assessments tab, click the Add button to open the Assessments window.
2. Click next to the Pain Intensity-Current field at the top of the window to open the
Pain Intensity-Current list. Each list is specific to the item selected in the View field.
3. Click the correct item from the list. Do this step again as many times as necessary to
complete the patient assessment.
Adding Assessment Notes
It is frequently important to include a note along with assessment items to clarify or expand
on an item.
1. Click the Note button to open the Assessments note window. The Assessments note
window operates the same as other note windows in MOSAIQ.
2. Type a subject into the Subject field, then press TAB. This adds the subject, then moves
the insertion point to the note box.
It is important that you type an accurate subject, because MOSAIQ
uses the Subject field to filter notes in the Patient Notes window.
3. Type your note into the note box.
4. Click the OK button to save the note. In the Assessments window, Y appears next to the
Notes item in the assessment list and appears next to the Note button.
Reviewing Assessment Observations
When you complete assessment observations, you must review them before you add them
permanently into the patient chart. You can change some or all items in an observation, or
remove a full observation, until you review it.
1. Click the Status button to open the Record Status dialog box. The Record Status dialog
box contains a list of all the observation items you added in the Assessments window.
You can also use it to review the items.
2. In the New Status group, click Reviewed to identify the observation status, then put the
insertion point in the Password field.
3. Type your password, then click the OK button to close the Record Status window.
4. Click the OK button to save the assessment.
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