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Assessment and Reassessment of Patients and Documentation in Clinics (8.02)

Assessment and Reassessment of Patients and Documentation in Clinics (8.02) - Policies, Clinical, UWHC Clinical, Department Specific, Ambulatory, Patient Care

8.02

8.02 Assessment and Reassessment of Patients and
Documentation in Clinics
Category: UWHC Departmental Policy
Policy Number: 8.02
Effective Date: October 22, 2014
Version: Revision
Manual: Ambulatory
Section: Patient Care (Ambulatory)
I. PURPOSE
To identify general assessment elements and parameters required of all clinical disciplines that assess and
reassess patients who present to UW Hospital and Clinics ambulatory settings for health care. To define
documentation of these elements.

II. POLICY
All patients seen in UW Hospital and Clinics ambulatory settings will receive an initial assessment and
subsequent reassessment, within a time frame clinically indicated. Indications of assessment are based on
patients’ unique needs respecting diversity, and applying standards of care and practice for the identified
discipline as warranted.

III. PROCEDURE
A. The goal of assessment is to determine the needs of the patient’s care, treatment and services that will
meet patient needs, acute, preventive and ongoing care.
B. Reassessment is based on clinical need, plan of care, changes in patient condition. Reassessments may
also be based on the patient’s diagnosis, desire for care, response to previous care, and/or setting
requirements.
C. The assessments/reassessments will be carried out by the appropriate clinical disciplines functioning
within their scope of practice and consistent with the policies and procedures of UW Hospital and
Clinics, Wisconsin State Statues, pertinent regulations and certification. This includes assistive
personnel (Medical Assistant and Licensed Practice Nurse) who gather and record data under the
direction and supervision of the Registered Nurse (RN), Nurse Practitioner (NP), Physicians Assistant
(PA) or Physician.
D. The following patient needs and conditions may be assessed: physical, psychological, social, spiritual,
pain, learning barrier style, and health history and maintenance, as warranted by patient’s needs and
condition. Consideration will be given to collecting information, as appropriate and with the patient’s
consent, from the patient’s family, care providers, outside medical records or medical jewelry.
E. Clinical assessment is based on the adult and/or pediatric ambulatory assessment parameters,
presenting problem and the clinic’s standards for assessment.
1. Assessments/reassessments MUST include but are not limited to:
a. Reason for visit or chief complaint.
b. Obtaining measurements according to department standards or guidelines: blood
pressure, pulse, respirations, temperature, height or length, weight, head
circumference.
c. Obtaining a list of allergies or adverse reactions.
d. Obtain use of tobacco.
e. Performing medication reconciliation by obtaining a current list of medications
from patient or caregiver. Documentation of patient’s perception of effectiveness
or side effects from medication, as appropriate.
f. Pain status will be screened at each visit by clinical staff as follows:
i. Clinical staff performing the patient clinical check-in will ask if the
patient has pain related to the reason for that visit.
 Will ask and record in the EMR location of pain, severity,
duration and quality of pain, as appropriate to the visit.

 Will use Pain Rating Scale, posted in exam room,
appropriate to age group and condition of the patient.
 Will alert provider if pain exists.
ii. Clinical staff will document other information in “comments” as
appropriate.
iii. Provider or Health Care Team will further assess and document pain
assessment and plan of care.
g. Clinical staff/assistive personnel performing the patient clinical check-in will ask
and observe for any learning or communication barriers. Documentation will be
in the appropriate section in EMR.
2. Additional assessments/reassessments MAY include but are not limited to:
a. Review of the problem list and past medical and surgical history, adding
information that has been documented in the EMR.
b. Nutritional and hydration status is assessed when warranted by the patient's
needs and condition. See Clinical Nutrition Policy 5.02 - Nutrition Assessment
and Reassessment of Outpatients in Clinic. Nutritionist will be consulted as
appropriate.
c. Functional status is assessed when warranted by the patient's needs and
condition. Rehabilitation/Health Psych therapies may be consulted as
appropriate.
d. The growth and development of children and immunization status is assessed in
the clinic providing ongoing primary care of the child. Pediatric patients seen in
specialty clinics are encouraged to obtain primary care from a pediatrician in
addition to their specialty care.
F. The scope and content of further assessment/reassessments are based on the patient's presenting
problem or health care need, diagnosis, the care setting, the patient's desire for care, the patient's
response to care, unique individual needs, or a significant change in condition.
G. Assessments and reassessments done by telephone follow the clinic specific telephone triage policy.
See Ambulatory Policy 8.20 Telephone Triage Standards in Ambulatory Clinics.
H. Diagnostic test results are reviewed by provider or designee per clinic workflows. Results are
addressed according to the clinic policy. See Ambulatory Policy 8.01 – Review of Diagnostic Test
Results and Notification to Patients.
I. Definitive laboratory tests used for patients in ambulatory care include those from the central clinical
laboratory and individually CLIA licensed, Point of Care (POC) laboratories. See UWHC
Administrative Policy 8.40 - Lab Point of Service Testing.
J. Assessments are made for at risk conditions such as physical abuse, substance abuse, suicide,
smoking, falls, pain, wound and skin breakdown, restraint use and age related needs.
1. The assessment, treatment and follow-up process for alleged victims of suspected
abuse or neglect are outlined in Administrative Policies 4.52 – Abuse, Neglect and
Domestic Violence, 4.44 – Guidelines for Evaluation and Treatment of Patients
Reporting Sexual Assault, and Child Maltreatment Guideline.
2. Patients expressing risk potential harm to self will be evaluated for suicide risk as
outlined in Ambulatory Policy 8.14 - Suicide Assessment and Intervention in Clinic.
3. Each clinic will evaluate patients for falls risk potential.
a. A falls risk assessment screening tool will be completed if falls risk behaviors
are observed.
b. Risk for falls will be documented in the FYI section of the EMR for all patients
and appropriate actions will be taken to protect the patient from falls in the
clinical setting.
c. The patient will be provided with falls prevention education and advised to
contact their primary care provider for further evaluation regarding increased
risk for falls.

K. Staff will communicate the identification of an existing falls risk to the patient’s primary care
provider.

IV. REFERENCES
2014 Joint Commission Standards
Clinic Specific Policies and Standards
Wisconsin Statutes relevant to professional practice
Clinical Nutrition Policy 5.02 - Nutrition Assessment and Reassessment of Outpatients in Clinic
Ambulatory Policy 8.20 - Telephone Triage Standards in Ambulatory Clinics
Ambulatory Policy 8.14 - Suicide Assessment and Intervention in Clinic
Ambulatory Policy 8.01 - Review of Diagnostic Test Results and Notification to Patients
UWHC Administrative Policy 8.40 - Lab Point of Service Testing
UWHC Administrative Policy 4.52 – Abuse, Neglect and Domestic Violence
UWHC Administrative Policy 4.44 – Guidelines for Evaluation and Treatment of Patients Reporting Sexual
Assault
Child Maltreatment Guideline

V. WRITTEN AND APPROVED BY
Ambulatory Policy and Procedure Committee
Clinics Administration

SIGNED BY
Karen Leimkuehler, RN, MS, Clinic Operations Manager