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Last updated on 2024年8月25日

How do you conduct comprehensive assessments of patients?

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Comprehensive assessments of patients are essential for effective case management and risk management. They help you understand the patient's medical, social, psychological, and functional needs, as well as their goals, preferences, and resources. By conducting comprehensive assessments, you can identify the patient's strengths and challenges, plan appropriate interventions, coordinate care, monitor progress, and evaluate outcomes. In this article, you will learn how to conduct comprehensive assessments of patients using a systematic and holistic approach.

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1 Prepare for the assessment

Before you meet with the patient, you should review their medical records, referral information, and any other relevant data. This will help you familiarize yourself with their medical history, current condition, diagnosis, treatment, and prognosis. You should also prepare a list of questions and topics to cover during the assessment, based on the patient's needs and goals. You may use standardized tools or instruments to guide your assessment, such as the Case Management Assessment Tool (CMAT) or the Risk Assessment Tool (RAT).

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Martha Rand

School Social Worker, LCSW, Certified Group Psychotherapist
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Assessments take place at various points. Sometimes an assessment is done by an intake worker. Sometimes the assessment is the professional's first meeting with the individual. Take into consideration the countertransference, the impressions, thoughts and feelings you have, as the assessor. Then find out how the individual who presents themselves for treatment sees themselves. This is a humanistic approach. Review the records and remember that the person in front of you is not simply the sum of the records on hand. First they are a person.

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Laura Daniels BSN, RN,

Founder?Registered Nurse ?Board Certified Patient Advocate ?Certified Dementia Practitioner ? Over 30 Years of Experience in Geriatric Care & Patient Advocacy
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Here are some ideas that can ensure that you are well-prepared to conduct a thorough and respectful assessment of your patient, leading to better outcomes and a more positive experience for both you and the patient. 1. Prepare by reading their history 2. Establish rapport 3. Understand their cognitive ability 4. Get to know their support system 5. Be aware of cultural sensitivities 6. Consider language barriers 7. Prepare for patient education 8. Prepare to address potential concerns

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Demetrius Kirk, DNPc, MBA,MSN, RN, LNHA, LSSGB, PAC-NE, QCP

Elite Healthcare Turnaround Executive | Healthcare Systems Transformation Expert | CMS Regulatory Expert | Operational Excellence Strategist | Executive Leadership Coach
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Effective assessment preparation requires the case manager to thoroughly acquaint themselves with standard assessment tools and meticulously review the patient's current diagnosis, medications, history and physical, and current interventions.

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NinaRose C.

Healthcare Professional with a Decade of Experience Specializing in Ambulatory Care, Transitional Care Management & Psych | MSN-FNP Candidate
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Reviewing medical records and preparing questions before meeting a patient is indeed a standard practice. It's like doing homework before a class; it helps us provide better care. Using tools like CMAT or RAT can be likened to using a compass; they guide us in the right direction during the assessment. This preparation is not just a task, but a commitment to our patients' well-being.

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2 Conduct the assessment

The assessment should be conducted in a respectful, empathetic, and collaborative manner. You should explain the purpose and process of the assessment to the patient, and obtain their consent and participation, while respecting their privacy, confidentiality, and autonomy. Ask open-ended questions, listen actively, and observe non-verbal cues to cover the various domains of the patient's situation. This includes medical factors such as physical health, symptoms, medications, allergies, complications, comorbidities, and adherence to treatment. Social factors include family, friends, support system, living situation, transportation, income, insurance, education, employment, and legal issues. Psychological factors include mental health, emotional state, coping skills, stressors, substance use, and behavioral issues. Functional factors include activities of daily living (ADLs), instrumental activities of daily living (IADLs), mobility, cognition, communication and self-care. Additionally you should cover their short-term and long-term goals, preferences, values expectations and motivation as well as their strengths assets skills knowledge and available services or programs.

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3 Document the assessment

After the assessment, you should document your findings, impressions, and recommendations in an objective, evidence-based, and accurate manner. Your documentation should include the patient's identifying information (name, date of birth, gender, contact details, and identification number), the date and time of the assessment and its duration, the tools or instruments used for the assessment and its mode of communication (e.g., face-to-face, phone, online), a summary of the main findings and conclusions organized by domain, and any suggested interventions, referrals, or actions based on the assessment that are aligned with the patient's goals and needs. To ensure consistency and accuracy in your documentation, you should use standardized terminology, formats, and codes.

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Dr.Ajay G.
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True assessment should be documented for future needs and also for medicolegal purposes Assessment along with empathy is required for truly assessing the patient

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4 Review and update the assessment

The assessment is not a one-time event, but a dynamic and ongoing process. You should review and update the assessment regularly, based on the patient's changing needs, goals, and circumstances. You should also communicate and collaborate with the patient and other members of the care team, such as physicians, nurses, therapists, social workers, and family members. You should use the assessment as a basis for developing, implementing, and evaluating the patient's care plan and risk management plan.

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5 Improve your assessment skills

As a case manager, you should strive to improve your assessment skills and knowledge. You should seek feedback from your peers, supervisors, and patients. You should also participate in continuing education, training, and certification programs. You should keep up with the latest research, best practices, and standards in case management and risk management. By enhancing your assessment skills, you can provide better care and outcomes for your patients.

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6 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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How do you conduct comprehensive assessments of patients?

1

2

3

4

5

6

1 Prepare for the assessment

2 Conduct the assessment

3 Document the assessment

4 Review and update the assessment

5 Improve your assessment skills

6 Here’s what else to consider

Case Management

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How do you conduct comprehensive assessments of patients?

1

2

3

4

5

6

1 Prepare for the assessment

2 Conduct the assessment

3 Document the assessment

4 Review and update the assessment

5 Improve your assessment skills

6 Here’s what else to consider

Case Management

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