Assessments - Frequently Asked Questions

This quick guide answers frequently asked questions about the Assessments screen in VieCure. It covers adding assessment types, how the Review of Systems (ROS) can be customized, and how WDL (Within Defined Limits) works in the Physical Exam.

 How do I add a new assessment type to the Assessments screen?

Assessments are built and managed in the Evaluation CMS, with the Assessments screen and the MAR Pre-Treatment Assessment using that content. Individual assessments are also added to a treatment plan from the Treatment Plan Flowsheet using Add Item to Plan: Assessment.

1. In the Patient Chart, click on Assessments. Click on Add New. Here you can either filter or scroll down to select the type of Assessment you want.
2. Example – Selecting Fall Assessment will load the questionnaire for completion. Once complete, hit Save.
3. A confirmation toaster will appear.

 How does WDL (Within Defined Limits) work within Physical Exam (Assessments screen)?

WDL lets you record a normal exam for a body system without picking individual findings.

1. Navigate to a patient's chart and select Assessments from the left-side navigation.
2. Click on PE (Physical Examination) tab you can select a Body System you need to the examination.

Other Useful Information

• Per body system — Each body system has a WDL (Within Defined Limits) toggle. Individual findings can still be set to Normal or Abnormal.
• Mutually exclusive — WDL and finding-level Normal/Abnormal selections cannot be on the same system. Selecting any finding turns WDL off for that system. Selecting WDL clears any Normal or Abnormal findings already chosen on that system.
• Mark All as WDL — This button at the top of the Physical Exam section applies WDL to every body system. If any system already has findings, you are asked to confirm because they will be cleared.
• Comments — Each body system has an optional free-text comment that does not change the WDL or Normal/Abnormal state.
• Note output — The system's standard WDL phrase (for example, for Respiratory: "Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi.") goes into the Normal section of the note, followed by the body system comment. No Abnormal text is written for a WDL system.
• Phrases and audit — WDL phrases are configurable per body system by an administrator. A WDL selection is timestamped and attributed to the documenting provider like any other physical exam entry. Genitalia show as Female or Male based on the patient's birth sex on file.