Action 5.11

Clinicians comprehensively assess the conditions and risks identified through the screening process

Intent

Patients receive comprehensive assessment to determine their healthcare needs and appropriate treatment options.

Reflective questions

What processes are in place for clinicians to ensure comprehensive assessment of patients’ conditions and risks that were identified through the screening process?

How does the health service organisation ensure that clinicians use these processes?

Key task

  • Ensure that clinicians talk to patients, carers and families about conditions and risks identified through screening processes, and work in partnership to comprehensively assess these conditions and risks.

  • Involve clinicians in evaluating and improving processes for comprehensive assessment.

Strategies for improvement

Hospitals

Comprehensive assessment relies on clinicians working with patients, carers and families to understand a patient’s current health status, and its effect on their life and wellbeing. Integrate usual clinical assessment processes (for example, investigation of the presenting condition) with assessments of specific conditions, issues and risks (for example, a pre-existing chronic condition, a behavioural issue relating to cognitive impairment, a social issue such as homelessness).

Clinicians from different professions and in different services may need to work together to develop a full picture of the patient’s needs. Use the processes for communicating critical information that are described in the Communicating for Safety Standard to ensure that assessment findings are effectively communicated.

Clinicians require training about organisational processes, as well as more specific training about the use of these processes at the ward, unit or service level. Provide orientation, education and training for clinicians on topics such as:

  • Professional roles, responsibilities and accountabilities in comprehensive assessment processes
  • When and how to use relevant assessment processes and tools
  • How to partner with patients, carers and families to optimise the identification of relevant information
  • How to communicate and document comprehensive assessment findings
  • When to repeat assessment processes in response to evolving conditions, issues or risks of harm
  • How to provide feedback about any issues with comprehensive assessment tools and processes.

Involve clinicians and consumers in reviewing the effectiveness and usefulness of assessment processes. Develop processes for ensuring that updates and changes to assessment tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that clinicians understand how to use and apply newly developed processes in their work, and have opportunities to provide feedback about usefulness and effectiveness of these processes.

Day Procedure Services

Comprehensive assessment relies on clinicians working with patients, carers and families to understand a patient’s current health status, and its effect on their life and wellbeing. In day procedure services, this may mean a focused assessment of the presenting issue and associated risks, rather than an in-depth assessment of a patient’s entire healthcare needs.

Clinicians from different professions and in different services may need to work together to develop a full picture of the patient’s needs. Use the processes for communicating critical information that are described in the Communicating for Safety Standard to ensure that assessment findings are effectively communicated.

Provide orientation, education and training for clinicians on topics such as:

  • Professional roles, responsibilities and accountabilities in comprehensive assessment processes
  • When and how to use relevant assessment processes and tools
  • How to partner with patients, carers and families to optimise the identification of relevant information
  • How to communicate and document comprehensive assessment findings
  • When to repeat assessment processes to address evolving conditions, issues or risks of harm
  • How to provide feedback about any issues with comprehensive assessment tools and processes.

Involve clinicians and consumers in reviewing the effectiveness and usefulness of assessment processes. Develop processes for ensuring that updates and changes to assessment tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that clinicians understand how to use and apply newly developed processes in their work, and have opportunities to provide feedback about the usefulness and effectiveness of these processes.

Examples of evidence

Select only examples currently in use:

  • Policy documents or by-laws that address
    • processes for assessing patients’ health status
    • identification of risks and actions required
  • Audit results of healthcare records for assessment of conditions and risks, for patients for whom screening was indicated
  • Assessment tools and resources for clinicians
  • Training documents about clinical assessment and assessment tools
  • Results of a workforce survey, and actions taken to address feedback on assessment processes, tools and resources
  • Standardised templates or forms for communicating critical information identified during assessment, such as email alerts or discharge summaries
  • Observation of the use of standardised assessment processes, tools and resources
  • Feedback from patients and carers about assessment.
MPS & Small Hospitals

Comprehensive assessment relies on clinicians working with patients, carers and families to understand a patient’s current health status, and its effect on their life and wellbeing. Integrate usual clinical assessment processes (for example, investigation of the presenting condition) with assessments of specific conditions, issues and risks (for example, a pre-existing chronic condition, a behavioural issue relating to cognitive impairment, a social issue such as homelessness).

Clinicians from different professions and in different services may need to work together to develop a full picture of the patient’s needs. Use the processes for communicating critical information that are described in the Communicating for Safety Standard to ensure that assessment findings are effectively communicated.

Clinicians require training about organisational processes, as well as more specific training about the use of these processes for the different services provided. Provide orientation, education and training for clinicians on topics such as:

  • Professional roles, responsibilities and accountabilities in comprehensive assessment processes
  • When and how to use relevant assessment processes and tools
  • How to partner with patients, carers and families to optimise the identification of relevant information
  • How to communicate and document comprehensive assessment findings
  • When to repeat assessment processes to consider evolving conditions, issues or risks of harm
  • How to provide feedback about any issues with comprehensive assessment tools and processes.

Involve clinicians and consumers in reviewing the effectiveness and usefulness of assessment processes. Develop processes for ensuring that updates and changes to assessment tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that clinicians understand how to use and apply newly developed processes in their work, and have opportunities to provide feedback about usefulness and effectiveness of these processes.

Last updated 29th May, 2018 at 11:21pm
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