Health care professionals conduct health assessment reports for a variety of reasons and patient populations. The setting and purpose of the assessment determine the format of and information included in the report. For example, a state school health assessment conducted by a school nurse will focus on a set of health criteria established by the state and school district, whereas a health assessment report prepared by a physician for an adult patient undergoing an annual physical may be more comprehensive and flexible in format. While parameters differ, a few common elements are present among assessments.
Begin with the patient's personal data including name, age, weight, height, Social Security number or identification (if appropriate), and parent information when applicable. Always include the date of the assessment and your name and credentials for the patient and other health care providers to reference.
List the patient's immunisation history. Include the dates of each prior immunisation, if known, and note any standard or recommended immunisation the patient does not have. If you are creating your own health assessment form, consider adding lines to document when any boosters or subsequent immunisation should take place. For patients who have acquired antibodies through disease -- as is often the case with varicella or chickenpox -- note the date of disease, if known, and corresponding titres.
Review known health problems such as diabetes, heart conditions and mental health disorders, including any corresponding medications the patient may take. When the health assessment is for the patient's use and benefit, include targets and goals related to known problems. For example, if a patient has high blood pressure, you might suggest the following goals: exercise for at least 30 minutes at least three times a week, take blood pressure medication and reduce intake of fats and sodium.
Record any hospital or emergency room visits the patient may have had within the last year. Include reasons for the visits and outcomes.
Document the patient's personal and lifestyle behaviours that impact health such as smoking, drinking and recreational drug use. Depending on the assessment purposes, scope and guidelines, you may include the patient's sexual health and history -- if he is sexually active, in a relationship and/or knowingly exposed to diseases such as tuberculosis or sexually transmitted diseases. Some reports include the patient's physical activities and sports. It may be appropriate to note a stressful life situation such as caring for an elderly or disabled family member, working in a high-pressure job or going through a divorce.
Note physical limitations or disabilities. With geriatric patients, health care providers measure mobility and range of motion. Many also assess self sufficiency in a variety of tasks and functions. The same goes for children based on developmental levels. Health care assessments often include any age-appropriate tasks, functions or abilities a child does not exhibit as well as learning and social challenges the child may face.
Conclude with any patient or provider concerns. Document any complaints the patient has regarding his health as well as any expected treatments or additional examinations necessary for known medical conditions. Note any issues you want to flag and review or refer to another provider for further investigation.
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