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The Patient Acuity Assessment page is the heart of the Outcomes-Driven Acuity application; it is also the page you will visit most frequently in this application. Caregivers go to the Patient Acuity Assessment page toenterand view each patient's outcome assessment and progress toward improved outcomes across the continuum of care.Outcome assessments can be generated by clinical documentation from the electronic health record (EHR) orbya direct entry approach. Cerner Clairviauses these assessments to calculate the patient's acuity level and the target staffing needed to care for the patient using Demand Manager.
Cerner Clairviaacuity methodology is most commonly based on Nursing Outcomes Classification (NOC), a familiar standard. However, Cerner Clairviacan accommodate other outcomes approaches as desired. Developed by the University of Iowa School of Nursing and licensed by Mosby, Inc., NOC is a comprehensive, standardized language of patient and client outcomes developed to evaluate the effects of nursing interventions.For more information about NOC, visit http://www.nursing.uiowa.edu/cncce/nursing-outcomes-classification-overview.
You start by selecting a patient. The page then gives you an assessment tool with an outcome set defined for the patient’s location and in some cases hospital service. The outcome set includes outcomes that are both relevant to the patient population the location serves and that can be assessed in a consistent manner whether using a direct entry assessment approach or if assessments are generated fromdocumentation entered in the EHR.
In NOC, each outcome has a group of associated indicators. You can click an outcome to see a list of its indicators; use this list to determine the patient/family state or behavior to be considered when assessing the patient status relative to the outcome. Ifassessments are generated from the EHR interface, the listincludes the indicators from the observation-outcome mappingthat can be usedwhen Cerner Clairviaautomatically generatesthe outcome assessment.
The content pane is divided into three sections:
- Assessment Date/Printable View
- Patient information
- Outcome set for assessment
The Assessment Date and Printable View Section
The first data displayed is the patient Assessment Date, which defaults to the current date and time. The application dates assessments as of the time you begin them. You can back-date new assessments to a date and time up to eight hours before the current date and time.
Clicking the Printable View icon lets you view and print the assessment in the content pane. You can print assessments to review and update manually before entering them inClairviaOutcomes-Driven Acuityor to include them in a patient's chart.
You can also print patient assessments using the Assessment History tab of the Patient Encounter Information window.
The Patient Information Section
The page displays the following patient information:
- Patient: The patient's name in Last Name, First Name format. If the patient's middle name and name suffix are in the application, the page displays these too (such as Doe Jr., John William). This information always matches the patient name you select in the navigation pane.
- PEN: The Patient Encounter Number assigned to the patient.
- Location: The patient's location according to the ADT transactions processed by Demand Manager.
- Admit Date/Time: The patient's admission date and time.
- Acuity Level: The patient's acuity level as of the last complete assessment. If there is no complete assessment on file, this cell is blank.
- Room/Bed: The room and bed the patient is in according to the ADT transactions processed byDemand Manager.
- Projected Departure Date: The date and time the patient is expected to leave the current location (for patients with location-based patterns) or transfer out of the current level of care (for patients with a criteria-based pattern). You can manage and update the projected departure date on the Administer Patient Pattern page of Demand Manager.
- Projected Discharge Date: The date and time the patient is expected to be discharged. You can edit the projected discharge date on the Administer Patient Pattern page of Demand Manager.
- Last Assessed: The date and time of the last assessment, complete, or incomplete. If a user completed the assessment by direct entry, you will see the letters DE next to the date and time. If a clinical documentation interface completed the assessment, you will see the letters IF next to the date and time.
- Service: The patient's assigned hospital service according to the ADT transactions processed by Demand Manager.
- Assessed By: The login name of the person who saved the last assessment. If there is no complete assessment on file, this is blank.
The Outcome Set Section
This section is where you make the actual patient assessment. There is a series of buttons for the outcomes set, along with descriptions and the appropriate Likert scale for the patient's location, location and hospital service combination, or both.
