Record and update patient assessments, vitals, and medications

When your cohort uses ePCR, open the patient evaluation’s patient-care-report sections to record findings and interventions. This applies to patient evaluations within shifts and to simulated patient evaluations where ePCR is enabled. Your program’s configuration determines which sections appear.

Record the initial exam and reassessments

1. Open Patient Exam in the patient evaluation editor.
2. Under Assessments, use the add-assessment action to create a set of findings, or select an existing assessment to edit it.
3. Record the findings for that assessment and return to the list.
4. Add another assessment when the patient’s condition changes, preserving the earlier findings in their original set.

For example, record the patient’s initial alert state in Assessment 1 and later changes in Assessment 2. Weight and Stroke/CVA resolved are exam-wide fields rather than separate values for each assessment set.

Assessment numbers follow the display order. On desktop, use the drag handle to reorder them; on mobile, press and hold a row and drag. Open an assessment and use its delete action to remove it. The remaining sets renumber. If you add a new set and leave without recording findings, the empty set is discarded.

The in-app summary shows the assessment sets in their saved order. The evaluation PDF does not include the detailed assessment findings; use the in-app evaluation when reviewing them. Use an up-to-date app on each device when working with multiple assessment sets.

Clone vitals or a medication administration

1. Open the Vitals or administered-medications list.
2. Open an existing entry and choose Clone beside its delete action. Alternatively, swipe right on the list entry to clone it.
3. Open the appended copy and review every value before keeping it. A vitals copy starts with the original recorded values; change them to match the new observation.

Cloning a medication with linked vascular access also creates a separate copy of that linked procedure. Review the copied administration and procedure so they represent what actually occurred.

Swipe left to delete an entry and review the confirmation. Deleting a medication also removes its linked procedure. You can also delete from the entry editor. Use press-and-hold reordering where offered in the list.

Use PreceptoBot with reassessments

If your organization enables PreceptoBot editing, specify whether you want to update an existing assessment or add a new assessment. For example: “Add a second assessment for the patient’s change in condition.” Review the proposed changes before applying them, including which assessment will change.

For starting the surrounding evaluation, see Filling out a shift evaluation or Filling out a simulated patient evaluation.