Assessment - Point of Entry in an Ongoing Process

Assessment is the collection of data about the individual's health state

"subjective data" is what the person says about himself or herself during history taking

"Objective data" is what you is the health professional observed by inspecting, per cussing, palpitating, and auscultating during the physical examination

together with the patient's record and lab studies these elements form the "database"

from the database you make a clinical judgment or "diagnosis"

the purpose of assessment is to make a judgment or diagnosis

all healthcare treatment and decisions are made based on the data you gather - it must be complete and correct

Diagnostic Reasoning in Clinical Judgment

"diagnostic reasoning" is the process of analyzing health data and drawing conclusions to identify diagnoses

it has four major components:

1. Attending to initially available cues

2. Formulating diagnostic hypotheses

3. Gathering data relative to the tentative hypothesis

4. Evaluating each hypothesis with the new data collected 

1. Assessment

COLLECT DATA

Review of the clinical record

interview

health history

physical examination

functional assessment

consultation

review of the literature

2. Diagnosis

INTERPRET DATA

identify clusters of cues

make inferences

Validate inferences

Compare clusters of cues with definition and defining characteristics

Identify related factors

Document the diagnosis

3. Outcome Identification

Identify expected outcomes

individualize to the person

realistic and measurable

include a timeframe

4. Planning

Establish priorities

develop outcomes

set time frames for outcomes

identify interventions

document plan of care

5. Implementation

Review the planned interventions

Schedule and coordinate the person's total health care

collaborate with other team members

supervise implementation of the care plan by delegating appropriate responsibilities

counsel the person and significant others

involve the person in the healthcare

refer individuals who require continuing care

document the care provided

6. Evaluation

Refer to establish outcomes

and evaluate the individual's condition and compare actual outcomes with expected outcomes

summarize the results of the evaluation

identify reasons for the person's failure, if indicated, to achieve expected outcomes stated in the plan of care

take corrective action to modify the plan of care as necessary

document the evaluation of the persons achievement of outcomes in the modifications, if any, in the plan of care