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Health assessments form the basis of care in healthcare settings. Be them acute or ambulatory, the assessment drives the care plan from the entire interdisciplinary team. Patients have a responsibility to report as much information as possible, and health care providers conversely have a responsibility to effectively pull that information out or observe and measure objective data accurately. The assessment types I am most accustomed to are focused assessments on an intermediate level of care floor. These can also be referred to as Step Down or Progressive care units. Our assessments are focused because patients come to us having been screened by emergency providers or providers at another level of care. These patients come to us with very specific needs and have to meet particular criteria for acuity and care to be on our floor. Once stabilized, we can move on to a comprehensive assessment taking into account not only acute or chronic symptoms or diseases, but socioeconomic issues for early discharge planning preparation. Key objective data at this level of care would be vital signs, lab values, results for radiological scans, physical assessments and making recommendations for other necessary testing to better drive care. Key subjective data would be obtaining information from the patient or family for onset of symptoms, medical history and lifestyle.
The typical patient population in my practice setting include people from the middle to upper classes. These patients are fortunately well versed in their medical history and care and often come in for planned procedures or follow closely with a medical team on the clinic side of the hospital. Special considerations necessary to obtain accurate health history have to be taken with this population because the general assumption is that all of the medical information is on the chart and nurses shouldn’t have to ask interview questions. This demographic also feels that once a question has been asked and answered once, it shouldn’t be asked again. This perception causes them to lose patience, increase frustration and give the impression that staff are incompetent. Unfortunately some information has to be re-asked as the answer can change, like a pain assessment or confirmation of emergency contact or code status. While alternative populations can prove to be challenging, this demographic presents its own complexity that can still require experience and finesse to provide optimal care.