ASSESSMENT

The aims of a full and detailed assessment are:

•  To identify and tackle problems (physical, mental, social, spiritual)

•  To increase trust

•  To plan for the future

Patients usually have many different problems. A full assessment demonstrates a serious intent to be in control of all the facts. The way it is done is a powerful message.

It is possible to ask questions at a first assessment that can be difficult to ask ever again.

Assessment includes:

•  History of illness

•  List of physicians involved

•  Inquiry about present symptoms

•  Discussion of drugs prescribed

•  Physical examination

•  Occupational history

•  Questions about financial worries, will

•  Family tree

•  List of forthcoming events (anniversaries, graduations)

•  Principal carers

•  Daily routine (?self care)

•  Home conditions

•  Religious beliefs, church membership

•  Insight

•  Assess priorities (What are your aims now?)

•  Make a plan

•  Follow up

A full assessment may take an hour or more, but it lays the foundation for a relationship of trust. Encourage joint assessments, but avoid repeated assessments by different team members. (“I’ve said all this twice already!”)

Make a note of any explanations you give. This improves team communication. Different explanations by team members can destroy the patient’s trust.

Avoid assumptions. When assessing a patient’s needs and priorities, remember that no two people are the same. The patient will often have very different priorities from your own (sometimes surprisingly so).

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.