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Screening, Assessment and Reassessment of Patients (3.5.2)

Screening, Assessment and Reassessment of Patients (3.5.2) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Patient Assessment

3.5.2


UW HEALTH CLINICAL POLICY 1
Policy Title: Screening, Assessment and Reassessment of Patients
Policy Number: 3.5.2
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 1, 2015

I. PURPOSE

To identify general screening, assessment and reassessment elements and parameters required of all
clinical disciplines that screen, assess and reassess needs of patients w ho present to UW Health for health
care.

II. POLICY ELEMENTS

A. All clinical disciplines have a policy, w hich delineates the scope, content and frequency of screening,
assessment and reassessment of patients cared for at UW Health.
B. All patients admitted to inpatient settings at UW Health w ill receive an initial screening, assessment and
subsequent reassessment as clinically indicated.
C. The scope and content of further assessment/reassessment are based on the patient's diagnosis, the care
setting, the patient's desire for care, the patient's response to care, or a signif icant change in condition.
D. The screening/assessment/reassessment w ill be carried out by the appropriate clinical disciplines
functioning w ithin their scope of practice and consistent w ith the policies and procedures of UW Health,
Wisconsin State statues, pertinent regulations and certif ication.
E. Standards of care, practice, assessment, and treatment protocols are developed by clinical disciplines as
w arranted to assure consistent levels of care.
F. Disciplines collaborate in analyzing and using assessment data and conclusions to identify and set
treatment priorities, w hich form the plan of patient care.
G. Each inpatient's physical, psychological, social and spiritual status, pain and health history w ill be screened.
H. Screenings are made for at risk conditions of all inpatients. These screenings include risk conditions such as
physical abuse, substance abuse, suicide, smoking, falls, pain, w ound and skin breakdow n, restraint use
and age related needs.
I. All inpatients receive a nutrition screening as part of the initial assessment. Nutritional and hydration status
is assessed w hen w arranted by the patient's needs and condition.
J. Functional status is assessed w hen w arranted by the patient's needs and condition.
K. All patients referred for rehabilitation service receive a functional assessment.
L. All inpatients, 10 years of age and older, receive a suicide screening as part of the initial assessment.
Outpatient and further inpatient assessment is determined by the physician as the condition w arrants.
M. For patients receiving end-of-life care, the social, spiritual, and cultural variables that influence the
perceptions and expressions of grief by the patient, family and/or signif icant others are assessed.
N. Specialized assessment and reassessment information is identif ied for specif ic populations served (for
example, Critical Care, Pediatrics, Psychiatry).
O. Discharge planning assessments are carried out upon admission to the inpatient service.

III. COORDINATION

Author(s): Director, Nursing Quality and Safety
Senior Management Sponsor: SVP, Patient Care Services and CNO
Review ers: Director, UW Health Home Care and Coordinated Care; Director, Orthopedics and
Rehabilitation; Pharmacy Manager, Nursing Quality and Safety Clinical Nurse Specialist; Geriatric Clinical
Nurse Specialist; Director, Respiratory Care; UW Health APP Director; Pediatric Pain Clinical Nurse
Specialist; Director, Surgical Services; Director, Health Information Services; Director, Nursing Practice
Innovation, Research and Evidence Based Practice; Director, Nursing Informatics; Director, Culinary and
Clinical Nutrition Services; Director, Emergency Services; Psychiatric Liaison Clinical Nurse Specialist;
Diabetes Clinical Nurse Specialist
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: October 19, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs



UW HEALTH CLINICAL POLICY 2
Policy Title: Screening, Assessment and Reassessment of Patients
Policy Number: 3.5.2

administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

IV. APPROVAL

Jeff Grossman, MD
UW Health CEO

Teresa Neely
SVP and CAAO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

V. REFERENCES

Department Specif ic Assessment Policies
Attachment A: Assessment/Reassessment Summary

VI. REVIEW DETAILS
Version: Revision
Next Revision Due: December 1, 2018
Formerly Know n as: Hospital Administrative policy #8.47