What is a simple assessment plan for a patient?

Simple Assessment Plan for a Patient

The assessment plan should be structured around the patient's specific clinical context, but a systematic approach includes: medical history review, physical examination, targeted testing, and documentation of a treatment plan with clear goals.

Core Assessment Components

Medical History

• Cardiovascular patients: Review current/prior cardiovascular diagnoses, procedures (including left ventricular function assessment), comorbidities (peripheral arterial disease, cerebrovascular disease, pulmonary disease, kidney disease, diabetes, musculoskeletal/neuromuscular disorders, depression), current symptoms, medications (dose, frequency, compliance), recent influenza vaccination status, cardiovascular risk profile, and educational barriers 1

• Geriatric patients (≥65 years): Apply the "Geriatric 5Ms" framework systematically 1:

  • Mind: Assess cognitive and psychological health first, as this influences all other domains; use validated tools like Mini-Cog (76% sensitivity, 89% specificity for dementia) 1
  • Mobility: Evaluate fall risk and functional status 1
  • Medications: Review and reconcile all medications, particularly high-risk medications using tools like Beers Criteria or STOPP/START criteria 1
  • What Matters Most: Identify patient's values, goals, and care preferences through advance care planning discussions 1
  • Multicomplexity: Assess how multiple chronic conditions and social determinants of health intersect to influence care management 1

• Psychiatric patients: Include reason for presentation, patient's treatment goals/preferences, psychiatric symptoms, trauma history, tobacco/substance use, psychiatric treatment history, psychosocial/cultural factors, and risk assessment for suicide and aggressive behaviors 1

• Diabetes patients: Assess interval medical history, medication-taking behavior and side effects, attainment of A1C and metabolic targets, risk for complications, diabetes self-management behaviors, nutrition, psychosocial health, and need for referrals/immunizations 1

Physical Examination

• Cardiopulmonary assessment: Pulse rate and regularity, blood pressure, heart and lung auscultation, lower extremity inspection for edema and arterial pulses 1
• Post-procedure sites: Examine cardiovascular procedure wound sites 1
• Functional status: Orthopedic and neuromuscular status, cognitive function 1
• Diabetes-specific: Blood pressure, genitalia examination (testicular size, penile fibrosis, retractable foreskin for erectile dysfunction screening) 1

Testing and Investigations

• Baseline tests: Resting 12-lead ECG 1
• Health status assessment: Use validated patient-reported outcome measures to assess perceived health-related quality of life 1, 2
• Cognitive screening (when indicated): Use structured tools like Mini-Cog, Montreal Cognitive Assessment (MOCA), or Memory Impairment Screen (MIS) rather than relying on unaided detection, which increases detection rates 2-3 fold 1
• Informant-based assessment (geriatric patients): Prioritize informant questionnaires like AD8 or Alzheimer's Questionnaire, as informants report functional decline more reliably than patients themselves 1
• Diabetes screening: Fasting glucose, lipid panel, renal function, liver function as indicated by history 1

Documentation and Treatment Planning

Document a comprehensive, patient-centered treatment plan that includes 1:

• Current patient status based on assessment findings
• Prioritized short-term goals (weeks to months) within each relevant care domain
• Specific intervention strategies for risk reduction
• Discharge/follow-up plan reflecting progress toward goals and guiding long-term prevention

Communicate the plan interactively with the patient and appropriate family members/domestic partners in collaboration with the primary healthcare provider 1

Medication Reconciliation (Critical Component)

• Ensure appropriate evidence-based medications are prescribed at correct doses (e.g., for cardiovascular patients: aspirin, clopidogrel, β-blockers, lipid-lowering agents, ACE inhibitors/ARBs per ACC/AHA guidelines; annual influenza vaccination) 1
• Review for high-risk medications in older adults using validated tools (Beers Criteria, STOPP criteria, Medication Appropriateness Index) 1
• Consider: Patient concerns, indications, risks, benefits, burden, drug-drug interactions, drug-disease interactions, time to benefit, and life expectancy 1

Patient-Centered Communication

• Use neutral, nonjudgmental, strength-based language that is person-centered and fosters collaboration 1
• Assess patient's self-efficacy for self-management, as this correlates with improved outcomes 1
• Elicit patient preferences, beliefs, and assess literacy/numeracy and potential barriers to care 1

Common Pitfalls to Avoid

• Do not rely on unaided clinical judgment alone for cognitive assessment; structured tools significantly improve detection rates 1
• Do not skip informant assessment in older adults, as patients may underreport functional decline 1
• Avoid using only chronological age to determine treatment eligibility; consider baseline functional and cognitive status 1
• Do not overlook medication review as a dedicated visit component, particularly in complex patients 1