Multidisciplinary anamnesis¶
The anamnesis is the guided intake of a resident, filled in shortly after admission, then updated whenever the situation changes. Each discipline writes its own.
Menu: Nursing Care → Care → Assessments → Anamneses, or New → Anamnesis on the care dashboard.
The principle: compose, never re-enter¶
An anamnesis is a dated snapshot per discipline, not a second copy of the record.
The resident’s facts (glasses, pacemaker, walking aids, weight, wishes…) are stored once on the resident and edited straight from the anamnesis. Correcting the weight here corrects it everywhere.
The structured clinical data (allergies, treatments, assessment scales) is reached by smart button, never copied.
Only the remarks and the general notes belong to the anamnesis itself: what that professional observed, on that date.
1. Create the anamnesis¶
Open Nursing Care → Care → Assessments → Anamneses and click New.
Pick the resident and the discipline: Nursing, Physiotherapy, Occupational Therapy or Speech Therapy.
The date defaults to today and the author is you.
Save.
One anamnesis per resident, discipline and date
WideCare refuses a duplicate for the same resident, discipline and date. To revise a same-day entry, edit the existing one. Only a resident with a stay in the house can be picked.
2. The Physical tab¶
Group |
Items |
|---|---|
Measurements |
Weight and height |
Senses |
Vision, contact lenses, hearing, dental status |
Cardiac Device |
Pacemaker, its rhythm and device number |
Mobility Aids |
Mobility, cane, crutches, walking frame, wheelchair (with its number) |
A free-text area holds the remarks on the physical assessment. These fields belong to the resident: they show on the resident’s form and in the other apps that need them.
3. The Autonomy tab¶
Free text for habits, rhythms and preferences for daily care.
4. The Wishes tab¶
In Case of Hospitalisation — preferred hospitals, refused hospitals, room type and complementary insurance. They feed the liaison pack printed at a hospital departure.
Advance Directives — DNR order, advance directive and its content, palliative status with its start date, and whether the resident and their representative agreed.
End-of-life Wishes — religion, funeral preference, will, burial concession, funeral contract.
Contacts — funeral home and notary, with their city.
End-of-life and hospitalisation instructions, and the remarks on the wishes.
Collected once, honoured everywhere
A DNR order or an advance directive entered here shows up on the resident’s form, where the care team sees it. Gather these wishes with the resident, and with their representative where applicable: the two agreement boxes record that this conversation took place.
The resident’s life story, habits, likes and projects are written in the life project, not in the anamnesis.
5. Notes and clinical context¶
The Notes tab holds the general notes of the anamnesis. Smart buttons open the existing record without leaving the page:
Allergies and Treatments, with their counters;
Evaluations — the scale suited to the discipline: Tinetti for physiotherapy, MMSE for occupational therapy.
In Belgium
The anamnesis also reaches the resident’s Katz assessments and their current category. See Care in Belgium.
6. Complete the anamnesis¶
When the intake is done, click Mark Complete. WideCare records the completion date.
State |
Meaning |
|---|---|
Draft |
Being filled in; editable and deletable |
Complete |
Part of the clinical record: no longer deletable |
A completed anamnesis cannot be deleted
It belongs to the clinical record. If it was completed by mistake, click Reopen: it returns to draft and becomes editable again.
The list filters by state (Draft, Complete) and by discipline, and groups by resident, discipline or state.
Key takeaways¶
The anamnesis is a dated intake per discipline, not a second record.
What the record already holds is composed, never re-entered.
The Wishes tab writes into the resident’s own wishes.
Mark Complete makes the anamnesis part of the clinical record.