identify main problem (from patients perspective) - considers subjective assessment, yellow flags (beliefs and judgement), red flags (serious pathology)
aids diagnosis - subjective assessment aids objective assessment
directs other parts of assessment (dig deeper in certain aspects during subjective and focuses objective assessment)
assists with setting meaningful, motivating goals with the patient/client (aids compliance)
assists in development of treatment/management plan
helps establish a rapport
Things to think about:
where is the assessment taking place
how long do you have to assess
what information can help you before you meet with them
where can you get this information from
introduce yourself and explain purpose
consent
time to write up
remember to sign and date
Where do we get information?
patient
family members
medical notes
observations
handover - nurses/doctors
colleagues
blood results
x-rays
be aware of acronyms
Notes:
have to be clear and readable
acronyms have to universal, so everyone knows what it means
Proforma:
how notes are normally set out - used as a prompt when doing a subjective assessment
