Basics Of Assessment Flashcards
What’s an assessment?
- the first thing we do to form a diagnosis or identity problems
- process of collecting info through reading, questioning, listening (subjective), observing, palpating, completing tests (objective)
- helps to form hypothesis of potential findings
- provides us with info on which clinical reasoning/management strategy will be based upon
- assists with documentation
- form treatment plan to document change/allow progression
Why’s an assessment important?
- legal documents that are required
- legal obligation to keep accurate records
- contains info of the condition of individual
- been made by or on behalf of professional involved with their care
Where can we gather info from and what might impact this?
- directly from the patient (could be confused, forget or they may perceive it as irrelevant)
- medical documents (might not be up to date or correct, have access to, or understand them)
- family members (might not be truthful/up to date, must have consent to speak with)
- other members of MDT
Types of info you would have in inpatient settings?
- full medical records in that trust
- some availability across different trusts/gp surgery
- xray, scans, d/c letters, referral letters, previous admissions, other mdt members
What types of info would outpatient settings have?
- similar to inpatient but might not have direct access
- less info to hand than inpatient
- gp referral letters
What info would a hospice or special school have?
- may be limited to specific hospice or school notes
- may have medical notes
- history of patient and care plans
What info would a private practice setting have?
- may not have any extra info if patients referred themselves
- might have insurance info of gp letter
What info might a sports physio have?
- similar to private practice
- depends upon the level of sport/athletes involved
Electronic notes system
- accessible by all clinical staff
- includes images, tests, theatre notes, up coming appointments, assessment documentation, personal data etc
- different systems depending on the trust/sometimes multiple systems within a trust
- confidentiality principles still apply
- can search by patients dob, nhs number, name
X shouldn’t write underneath someone else’s log in
Why should we avoid abbreviations?
- tighter regulations now
- only use accepted medical terms e.g. bp/hr
- always check protocol before using
- usually not allowed on online systems but seen more often on paper notes
Basis of good note writing.
- chronological order
- record factual info
- use patients quotes
- title
- date and time
- accurate/completed in timely mannner
- sign name
- neat, tidy and legible
-no/limited abbreviations - page numbers and patients name, dob, nhs number on each page
What goes in the subjective part of soap notes?
PC - presenting condition
HPC- history of presenting condition
PMH- past medical history
DH- drug history
SH- social history
- consent
- whose present
- time you’ve seen patient/contact with carer, mdt
What goes in the objective part of soap notes?
- medical observations (hr,bp,RR, auscultation, oxygen)
- general assessment (what can u see? What are you observing?)
- where they are in the room, what they look like/are wearing
- do they have any postural deformities
- any attachments to them, how are they breathing, any specialist equipment (wound dressings, skin integrity)
- palpating (do they feel different)
- ROM of joints
- treatment (interventions, exercise, education, manual techniques)
- reassessment (changes to patient during observations)
What goes in the analysis section of soap notes?
- summary of findings from other sections
- patients perspectives/goals (short term, long term, SMART)
- patient’s problem list
- clinical reasoning, justify interventions/treatment plans
- precautions/contradictions
- potential prognosis
What goes in the plan section of soap notes?
- assessment findings
- treatment plan
- related to analysis and problem list
- prioritised, objective, repeatable
- time scale for next session
- who is the plan in relation to?
