ASSESSMENT REBRIEF By Joan Watt, MSMA, MCSP

This article provides the foundation for a series of assessment articles focusing on specific areas of the body. The articles on specific areas will include video clips of the assessment being performed and the tech- niques used during this assessment.

WHAT IS ASSESSMENT? This can be described as the systematic gathering of information to give an informed, reasoned explanation for an episode or occurrence. This should provide enough information to allow the health professional involved to make an educated decision on the correct course of action. This may include direct treatment or refer- ral to another health carer or to request additional input from another source.

There should be two distinct but linked parts to all assessments: 1) History taking 2) Examination

This process should give the practitioner a clear idea of which structures are involved, what needs to be done to them and provide clear treatment goals. The baseline to mea- sure treatment outcomes and allow audit should also be identified and this in turn prevents treatment of contraindicated conditions.

The basic difference between diagnosis and assessment is that the ultimate aim of diagnosis is to assign a name or label to a certain group of signs or symptoms. Assessment need not necessarily name a condition as long as it identifies the prob- lem, ascertains which structures require treatment and ensures that there are no contraindications pertaining to the chosen intervention.

HISTORY TAKING This must involve the following elements: ■ Record taking

■ Client details

■ Informed consent ■ Signed consent ■ Confidentiality ■ Chaperone

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PAIN FREE Figure 1. Pain scale 8

■ Child protection ■ Duty of care

“WHAT’S YOUR PROBLEM?”

A READY RECKONER TO PATIENT ASSESSMENT

RECORDS It is essential that all health care profes- sionals ensure they keep clear, accurate records. The ultimate question is, if you were ever to be sued would your records satisfy the legal requirements and stand up to the scrutiny of an expert witness?

These records must be legible and written in permanent ink within 24 hours of con- sultation and treatment. Correction fluids must not be used and all alterations must be initialled. All entries are dated and ini- tialled. Any advice, even given over the telephone, must be recorded. The practi- tioner’s full signature has to be written on each page of the patient’s notes. Records have to be stored in lockable containers accessible only to those involved in the patient’s care. Patients have the right of access to their own records post-November 1991. Computerised records involve the Data Protection Act and must only be accessible to those involved. Records have to be kept for at least seven years and in the case of a minor, to a minimum age of 21. The advice given by the legal experts is to keep records for eight years and up to the age of 25 for minors.

Client details The patient’s details must be fully recorded on the first page and their name, date of birth or unique treatment number should appear on all subsequent pages.

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MINOR ANNOYANCE, TWINGES

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ENOUGH TO DISTRACT

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CANNOT BE IGNORED BUT DOES NOT INTERRUPT NORMAL ACTIVITIES

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INTERRUPTS SOME ACTIVITY, AFFECTS CONCENTRATION, TOLERABLE WITH EFFORT

Informed/signed consent There must be provision for a signed state- ment that the person agrees to being treat- ed, has been informed about the treatment and is capable of giving informed consent. If the individual is not able to give informed consent, then the person doing so on their behalf must be fully identified and provide a signature (see Further reading).

Confidentiality All information in the patient’s record is confidential and cannot be released with- out that patient’s written consent. The only exception is if you think that person is a danger to themselves or another per- son. Then ensure you note all of your rea- sons why and what you are doing and above all your justification for that course of action (see Further reading).

Child protection and chaperone It is now essential that all health care pro- fessionals have had an Enhanced Disclosure Certificate from their local Criminal Records Office. A chaperone is also essential when working with minors - remember the age for a minor differs in parts of the UK. It is 18 years in England and Wales, 17 in parts of Ireland and 16 in Scotland. It is also sensible in the case of male practitioners treating females and it is good practice to have a sign up explain- ing the patient is welcome to invite a chaperone to be present.

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ALL ACTIVITY IS LIMITED

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