CareNotes

Article 10 “Clinical Assessment”

AHCA has published the report “Building Prevention into Every Day Practice: A Framework for Successful Clinical Outcomes.” The framework was built by the AHCA Clinical Practice Committee with the goal of developing solutions for reducing rehospitalizations and adverse events. Quality of care drives business success or failure in long term and post-acute care. This framework acknowledges that clinical results need both an organizational and a clinical foundation. This framework report consists of 13 articles. Below is the 10th article in the series.

Clinical Foundation: Clinical Assessment

What does this mean?

A clinical assessment is a systematic way to obtain and document information about an individual’s medical and psychiatric conditions and symptoms, function, behavior, personal history, values, preferences, goals, and other relevant information, and which is then analyzed using clinical reasoning to identify underlying causes of conditions and symptoms and to choose pertinent interventions.

The clinical assessment typically entails both asking questions and making direct observations, including details about the nature, duration, location, intensity, and severity of the individual’s symptoms and concerns. Clinicians may also use standard tests and checklists to help clarify aspects of an individual’s health and illness.

Why is this important?

A thorough clinical assessment identifies issues precisely to enable high quality care (care that is safe, effective, efficient, timely, equitable, and person-centered). High quality care is the principal route to reducing adverse events, including those that lead to hospitalization.

What are some examples?

• Assessing someone with persistent nausea and vomiting involves obtaining a chronological story and a detailed description of symptoms and examining the abdomen.
• Assessing behavior means getting details (frequency, intensity, and duration), a detailed chronological story, background information about the person’s past history and predisposing factors, observing and describing the individual’s actions and reactions, describing related considerations including appearance and thought processes, and looking for any other clues such as altered level of consciousness.
• Assessing acute pain means getting pain symptom details (frequency, intensity, and duration, relieving and exacerbating factors), a detailed chronological story, background information about the person’s underlying conditions and recent history; touching and palpating the painful area while observing and describing the individual’s actions and reactions, and seeking and describing related findings such as bruising, redness, or swelling.
• Some assessments are fixed (predetermined); for example, the Minimum Data Set (MDS) or a facility’s standardized fall risk assessment; others (such as the story of current symptoms related to an acute change in condition) are variable (i.e., not predetermined); that is, the content and format depend on the situation.

There are many formal and designed assessment tools and guides. Some are discipline specific while others are more generic. Many nursing and medical references offer detailed explanations of how to assess a person. For example, INTERACT offers guided assessment to help staff document and prepare a meaningful report to a health care practitioner about a change in condition through SBAR.

Regardless of the format or source of any assessment tool, assessment has certain key components, including observation, hands-on evaluation, description, a sequential story of the situation, documentation and reporting of details, and subsequently interpretation of the assessment information including drawing conclusions about likely causes.

What is my part (as an individual employee, manager or practitioner)?

• Perform an accurate and adequate assessment of each situation, to support subsequent interpretation and clinical decision making.
• Learn more about the different aspects of assessments; for example, making observations, deciding what and how much information is needed, and interpreting the meaning of information.
• Interpret findings prudently based on knowledge of the resident/patient and on understanding how to interpret the information.
• Know and respect your capabilities and limitations at interpreting information, so you do not contribute to harm due to mistaken interpretation.
• Try to strengthen your skills at observing, describing, defining, documenting, and reporting information and strive to improve your knowledge of how to assess specific conditions and situations (falls, confusion, weight loss, etc.).

What can my organization do?

• Teach and coach staff about the proper approaches to assessment.
• Check staff understanding of how to observe, examine, describe, define, document, and report information.
• Check that staff know how to organize, document, and report information as a coherent and meaningful story about a condition or situation.
• Help staff access references and resources that explain components of various assessments, whether comprehensive or focused, and check that the resources are used as needed.
• As part of the QAPI program:
  • Review assessment quality (for example, by reading and critiquing nursing and other progress notes) and look for ways to improve the documentation and reporting of information.
  • Evaluate the accuracy and pertinence of conclusions reached on the basis of assessments, to be sure that staff are not exceeding the scope of their training and knowledge and that residents / patients are not having adverse consequences such as hospitalization as a result of inadequate, incorrect, or misinterpreted information gathered during assessments.

Resources

LeBlond RF, Brown DD, DeGowin RL. DeGowin’s Diagnostic Examination. (9th ed). New York:McGraw-Hill, 2008

Stern, Scott; Cifu, Adam; Altkorn, Diane (2014-10-28). Symptom to Diagnosis An Evidence Based Guide, Third Edition (Symptom to Diagnosis: An Evidence-Based Guide) (Kindle Location 15659). McGraw-Hill Education. Kindle Edition

Teaching Clinical Reasoning (Teaching Medicine Series). American College of Physicians, 2015 31 Developed by American Health Care Association Clinical Practice Committee November 2015

Nursing assessment handbooks, references, etc.

SBAR Toolkit

Key Takeaways: Clinical Assessment

• A thorough clinical assessment identifies issues precisely to enable high quality care.
• Clinical assessment has various components (observation, interpretation, etc.) and a given health care professional or licensed staff person may not be equally adept at all of those aspects.
• Performing an accurate and adequate assessment enables subsequent interpretation and clinical decision making.
• Interpretation of findings must be done prudently based on knowledge of the resident/patient and on understanding how to interpret the information, not just on knowledge of the topic (falls, behavior, pain, etc.)

Probing Questions for Team Reflection and Discussion

1. How good are the assessments that our staff and practitioners do?
2. Are we getting enough information and organizing it effectively to allow for appropriate interpretation?
3. Do we obtain a chronological story and useful background information to support our assessments of all situations and symptoms?
4. Do we focus enough on improving the processes, not just the tools (forms, etc.)?
5. What factors impede completion of thorough and accurate clinical assessments? How can we address and minimize those factors?