Make a Health Assessment Plan
Health assessments are frequently done in conjunction with treatment plans. Before doctors begin a specified treatment they assess a patient's current state of health. That requires them to collect medical data from the patient. Doctors want to know whether the patient has had serious illnesses or operations. The results of the health assessment help doctors design an individual treatment plan that may include prescription medicines, therapy and/or surgery.
Instructions
1. Start the assessment plan by stating the reason, or "indication", for the assessment. For example, emergency staff assessing a patient's mental health usually begin by identifying the event or situation that brought the patient to the hospital. It could be that the patient suddenly seems out of touch with reality or has stated a desire to commit suicide.
2. Continue the assessment with specifics on the patient's behavior. For mental health assessments, the doctors at Medlaw.com suggest the assessor report the patient's posture, gait, facial expressions, ability to make eye contact with staff and the patient's attention span.
3. Observe the patient as you prepare the assessment. Then record the patient's motor level-whether it is normal or hyperactive-and any noteworthy mannerisms, such as pacing or hand wringing.
4. Ask the patient questions about his or her medical history. Find out whether the patient's parents are still alive. If they are, find out their ages and their state of health. If they aren't, find out how they died and the cause of their death as well as their age at death.
5. Find out whether the patient has been involved in an accident, either recently or within the past year. This is important for patients at pain management clinics. For example, if a patient comes to the clinic complaining of back pain, a nurse will ask whether the patient has injured his or her back in a motor vehicle or work place accident.
6. Discuss the patient's recreational activities which might be contributing to a pain syndrome. For example, if a patient complains of knee pain or stiffness, doctors at the Pain Management Clinic at UC Irvine will ask whether he or she runs regularly or takes part in sports since both activities can lead to muscular complaints.
7. Notice how the patient answers your questions, which is especially important for mental health assessments. Doctors at Medlaw.com use an assessment plan form that considers the speed of the patient's speech and the patient's thought processes as he or she is responding to questions. For example, does the patient's response seem logical and coherent or does it seem the patient is rambling on about a variety of topics that have nothing to do with the subject of the question?
8. Collect historical data from the patient that seems relevant to their current medical complaints. For example, when patients present to the vaccination clinic in Santa Barbara County, the Public Health Department there completes a health assessment that asks whether the patient has had autoimmune diseases, serious skin conditions or burns, is undergoing cancer treatment, has been pregnant and whether the patient is currently nursing.
9. Finish the assessment plan by identifying who made the assessment. The assessor should also sign and date the form.
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