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Patient assessment is the term used to describe the process of identification of the condition, needs, abilities and preferences of a patient. Most assessment tests are done by a nurse, but emergency medical crew members, physicians or other qualified medical personnel also perform these assessments. Health assessments consist of an interview with the patient, observation of the patient and any signs or symptoms he or she might display, review of patient's medical and social history and a determination of the general state of a patient's physical and mental health status.
The first stage of patient assessment consists of a physical assessment. A health care professional seeks to records vital signs, including coloration and condition of skin, motor skills, sensory function, nutrition, elimination, activity, rest and sleep patterns and state of consciousness. Part of the physical stage of assessment includes a pain assessment that generally asks a patient to rate her pain on a scale of 1 to 10. These factors, when considered in relation to one another, can give important clues to what illness or condition might be causing a patient's health problem.
Following physical characteristics, the social and emotional factors affecting the patient's well-being are explored. There are many important factors in the social assessment, including religion, career, mood, emotional tone, responsibilities, family ties and attitude toward health care, doctors and medical facilities. This information is the second piece that helps guide doctors and medical personnel in putting together a complete plan of care to help stabilize or heal a patient.
Other optional stages of assessment are situational. Many emergency medical personnel must also assess the environment in which the patient is found in order to determine if there are factors that might need to be considered that normally would not be at issue. Exposure to extreme heat, cold or other weather situations can cause complications to injury or illness for which symptoms should be monitored. Preventive treatments might also be called for in these situations. Suitability assessments can determine if a patient might meet the criteria to receive a transfusion, transplant, experimental treatment, surgery or other treatment that is based on adherence to certain criteria.
A mental health assessment can often accompany a patient assessment in an attempt to determine whether a patient is competent enough to make decisions regarding their medical care, living arrangements or financial affairs. Sometimes a mental health assessment can uncover suicidal or depressive tendencies that manifest themselves psychosomatically, giving clues that perhaps the plan of care should include or even be limited to psychological counseling or a psychiatric referral being made. These types of assessments are often called upon as evidence in competency or custody hearings.
Patient assessment is a skill that is developed over time and with study and practice. Good listening skills are essential in the art of effective patient assessment. Medical personnel who can connect well with a patient and establish a level of trust and respect provide the most effective patient assessments. An assessment that is off the mark can cause tremendous harm through the lack of proper and necessary treatment or by giving unneeded treatments that can adversely affect the patient's true condition by masking real symptoms or causing unpleasant or even deadly side effect.
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