What is the assessment plan for a patient?

Assessment Plan for Patients

The assessment plan should begin with a comprehensive evaluation encompassing medical history, physical examination, and targeted testing, followed by documentation that guides treatment planning and ongoing monitoring.

Core Assessment Components

Medical History

A thorough medical history forms the foundation of patient assessment and should include:

• Current and prior diagnoses including cardiovascular, pulmonary, neurological, endocrine, and psychiatric conditions 1
• Medication review with attention to dose, frequency, compliance, and identification of high-risk medications 1
• Symptom assessment including onset, duration, severity, and functional impact 1
• Comorbidities such as diabetes, kidney disease, musculoskeletal disorders, depression, and substance use 1
• Psychosocial factors including social support, living situation, cultural considerations, and what matters most to the patient 1
• Trauma history and psychiatric symptoms to identify underlying mental health conditions 1

Physical Examination

The physical examination should be systematic and targeted:

• Vital signs including pulse rate, regularity, and blood pressure 1
• Cardiopulmonary assessment with auscultation of heart and lungs 1
• Extremity examination for edema and arterial pulses 1
• Cognitive and mental status evaluation including screening for delirium, depression, and dementia using validated tools 1
• Mobility and fall risk assessment as part of geriatric evaluation when applicable 1
• Functional status including ability to perform activities of daily living 1

Diagnostic Testing

Initial testing should be guided by clinical presentation:

• Resting 12-lead ECG for cardiac patients 1
• Laboratory investigations based on history and examination findings, avoiding redundant testing 1
• Quantitative symptom measures to establish baseline severity and track treatment response 1
• Cognitive screening tools such as the Mini-Cog when cognitive impairment is suspected 1

Treatment Plan Development

Documentation Requirements

Document a comprehensive, person-centered treatment plan that includes:

• Patient assessment data reflecting current status and identifying priority problems 1
• Short-term goals (weeks to months) within each relevant domain of care 1
• Intervention strategies for risk reduction and symptom management 1
• Evidence-based pharmacological and non-pharmacological treatments 1

Patient Communication

• Interactive discussion of the treatment plan with the patient and family members in collaboration with the primary healthcare provider 1
• Elicit patient preferences and meaningful health outcome goals to ensure alignment with what matters most 1
• Provide developmentally appropriate explanations using multimodal approaches when needed 1

Ongoing Monitoring

Follow-up Planning

Establish a discharge and follow-up plan that:

• Tracks progress toward goals and guides long-term management 1
• Includes scheduled reassessment at specified intervals (e.g., weekly during hospitalization) 1
• Monitors treatment effectiveness through defined measurements including symptom scales, functional status, and quality of life 1
• Screens for side effects and complications of treatment 1

Communication Across Settings

• Transfer documentation should include nutritional data, care plans, and assessment findings when patients move between care settings 1
• Coordinate with specialists when metabolic, functional, or psychiatric issues require expert assessment 1

Special Considerations

Risk Assessment

• Suicide and aggression risk must be evaluated in psychiatric patients using standardized tools when appropriate 1
• Fall risk and mobility impairment require specific attention in older adults 1
• Nutritional screening should identify patients at risk for malnutrition and link to appropriate interventions 1

Common Pitfalls to Avoid

• Do not rely solely on laboratory values (e.g., albumin) as markers of nutritional status, as they often reflect disease severity rather than malnutrition 1
• Screen for depression and anxiety systematically, as these conditions are frequently undertreated despite high prevalence 1
• Ensure medication reconciliation occurs at every transition of care to prevent errors 1
• Consider cognitive impairment's impact on all other assessment domains and treatment adherence 1