What is the recommended approach for patient assessment?

Recommended Approach for Patient Assessment

A comprehensive patient assessment should include standardized evaluation of physical, mental, and psychosocial factors, with documentation using validated assessment tools specific to the patient's condition and context of care. 1

Core Components of Patient Assessment

Initial Assessment Framework

• Medical History and Present Illness:
  • Document reasons for evaluation 1
  • Conduct psychiatric review of systems (for mental health patients) 1
  • Assess past and current diagnoses 1
  • Document medication history including prescriptions, over-the-counter medications, supplements 1
  • Evaluate sleep patterns and abnormalities 1

Physical/Clinical Assessment

• Standardized Physical Assessment:
  • Use validated, standardized instruments appropriate to the condition 1
  • For stroke patients: Use National Institutes of Health Stroke Scale (NIHSS) within first 24 hours 1
  • Evaluate physiological and functional status 1
  • Screen for specific deficits (motor, sensory, cognitive, communication, swallowing) 1

Mental Health Evaluation

• Psychiatric/Psychological Assessment:
  • Screen for depression and anxiety 1
  • Assess suicide risk and history of suicidal ideation/attempts 1
  • Evaluate impulsivity and risk of aggressive behaviors 1
  • Use quantitative measures to identify symptom severity 1

Psychosocial Context

• Social and Environmental Factors:
  • Assess patient's background, relationships, life circumstances 1
  • Evaluate strengths and vulnerabilities 1
  • Document living situation and support systems 1
  • Identify barriers to care (language, health literacy, access issues) 1

Pain Assessment

• Pain Evaluation:
  • Use standardized pain scales (VAS, VRS, NRS) 1
  • Assess quality of pain (nociceptive vs. neuropathic) 1
  • Document pain intensity, location, duration, and temporal patterns 1
  • Evaluate impact on function and quality of life 1

Special Considerations

Multi-Informant Approach

• Involve family members/caregivers when appropriate 1
• Consider multiple sources of information for pediatric/adolescent assessments 1
• Be aware that different informants may provide complementary information about functioning in different contexts 1

Palliative Care Needs

• Screen for palliative care needs in patients with metastatic solid tumors 1
• Assess personal goals and expectations before symptom assessment 1
• Discuss benefits/risks of anticancer therapy in advanced disease 1

Multimorbidity and Polypharmacy

• Conduct medication reviews at least annually, more often if needed 1
• Evaluate potential drug interactions and adverse effects 1
• Assess disease and treatment burden on daily life 1
• Document all diagnoses and conditions in electronic medical record 1

Implementation Recommendations

Assessment Timing and Frequency

• Initial assessment should be thorough and comprehensive 1
• Follow-up assessments should be scheduled based on clinical need 1
• For chronic conditions, regular reassessment is essential 1
• Consider modular approach with different assessment frequencies for different domains 1

Reducing Patient Burden

• Balance assessment comprehensiveness with patient burden 1
• Involve patients in decisions about assessment schedule 1
• Consider using a modular approach where not all measures are delivered at every time point 1

Documentation and Communication

• Share assessment findings with patients and family members 1
• Document using standardized formats in electronic medical records 1
• Use assessment results to determine appropriate level of care 1
• Develop comprehensive, person-centered treatment plans based on assessment findings 1

Common Pitfalls to Avoid

• Failing to use validated, standardized assessment tools 1
• Overlooking psychosocial factors that impact health outcomes 1
• Not involving patients in the assessment process 1
• Conducting assessments without clear purpose or follow-up plan 1
• Focusing only on disease-specific measures while missing overall functioning 2
• Neglecting to reassess patients as their condition changes 1

By implementing this structured, comprehensive approach to patient assessment, clinicians can improve diagnostic accuracy, develop more effective treatment plans, and ultimately improve patient outcomes related to morbidity, mortality, and quality of life.