Assessment documents and PDFs

Open Assessments in the clinical navigation. Use the records view to reopen existing work and the catalog to inspect available content versions.

Create an assessment document

Select Start Assessment and choose Assessment method.

Choose Write a clinical assessment document for your own report, Record external publisher results and PDF for an externally completed assessment, or Administer configured assessment items for an authored content version.

Use Find patient, select the participant, and set Assessment date. For item administration, select Content version.

Select Create assessment draft.

Complete purpose and referral question; participant and assessment context; consent, assent and participation; methods; assessment narrative; limitations; interpretation; recommendations; and author credentials and license information.

Select Save draft and wait for Draft saved before leaving.

If a catalog card reports incomplete content, use its document-writing action or start the written-document method. A catalog title or advertised item total does not establish that an item version is ready for administration.

The ✨ icon beside each narrative label is the spelling and grammar correction action. Clinical documents use manual writing and local text suggestions, so cloud correction remains disabled here. The icon's tooltip explains its availability. Copy, clear, and dictation tools appear in the top bar while a text field is active; dialog forms keep those tools inside the dialog header.

iPad assessment editor with compact correction icons beside field labels and text tools in the top bar

Open the desktop example. Both examples use synthetic staging records.

Upload or link a PDF

In Evidence and source documents, choose Upload source PDF to select a PDF from the device, or Link patient document for an existing participant document.

Wait for the upload to finish. Supply the evidence label, date, source type, and observer, author, or source.

Open the source PDF link to check the document, then Save draft.

Use Add observation or source for direct observations, interviews, or record-review notes. Link relevant evidence to item observations and framework occasions where those sections are used.

An uploaded PDF supports the report; it does not fill the narrative or establish a clinical conclusion automatically. Resolve an upload failure before treating the attachment as saved.

Record observations without confusing zero with untouched items

Choose an Observation state for each configured item. Not assessed retains an unresolved item. Assessed numeric score enables that item's authored score options and criteria. Not applicable, Unable to assess, and Declined record distinct outcomes, with an exception reason where required.

A numeric zero is an assessed result only when you explicitly select it for an assessed item. Use the displayed instructions, measurement definition, observation context, and evidence links. Record unavailable information honestly instead of filling it with a numeric zero. Historical numeric records retain their ambiguity until reviewed through an amendment.

Barrier and readiness observations records original descriptive observations. Add an occasion with date, observer and supporting evidence, and document the observable criterion for each rating. These ratings are not standardized scores.

Complete, review, and download

Read outstanding issues under Clinical review and correct the referenced content.

Confirm the review attestations after checking evidence, limitations, consent, and interpretation.

Complete administration saves that status, but the report still needs review. Review and lock report saves a reviewed, locked version.

Use Download report PDF. Check participant identity, date, assessor, credentials, narrative, results, and evidence before sharing. A draft download is not a reviewed report.

Desktop reviewed assessment showing saved status, PDF download and report-signature entry

Open screenshot at full size

Synthetic staging record. No signature request has been prepared in this example.

Correct a reviewed report

Under Amend this reviewed record, enter an Amendment reason and select Create amendment draft. Edit and review the new draft. The earlier reviewed record stays intact. A historical record can be converted into a linked assessment document using its amendment action.

Continue to Adult FBA and BIP, External results, or Report signatures.