Patient Assessment and Reassessment
 
Policy: 
Assessment and Reassessment conducted in this organization are within the scope of practice of the organization and within the state licensure laws and applicable regulations of the discipline of the individual performing the assessment or 
reassessment. This organization accepts patients for care, treatment, and services based on the patient's need. 
 
Initial Assessment Procedure:
While the patient is sitting in the waiting room, they will complete an intake form that will assist the clinical staff and physician in completing the assessment. The intake form will consist of demographics as well as questions regarding psycho/social information, medical and surgical history, medications,(this includes all over the counter, herbals and vitamins)and allergies. This information is necessary to determine the patient's eligibility for entry to the organization. Additionally, the intake form will assist in beginning to define the patient's physical, cognitive, and psychosocial status.  
 
The patient and accompanying family (or surrogate decision-maker) is then seen in the physician's office. The patient makes the decision regarding family members presence during any portion of the assessment. The clinical staff and or physician interview the patient verifying the information received on the intake form.  At this time the staff will begin to identify possible barriers to treatment or services, which would include social barriers, environmental factors, physical disabilities, vision or hearing impairments,  developmental disabilities, cognitive disorders, emotional and mental disorders, and substance abuse. This process provides the physician and clinical staff with data that will assist in the formulation of decisions for treatment and services for this patient.  If this is a patient, previously seen within the organization the patient will be question regarding any changes in their medical surgical history, medications, and allergies since the last visit.  If the patient has not been seen by the organization in over one year, the patient will be asked to update or complete a new demographic form.  All patients are queried as to their expectation(s) of their visit. The patient is then examined in the exam room, with the assistance of the clinical staff. All significant findings, i.e. laboratory results, significant psycho-social findings, etc. that have been sent to the organization from any referring physician are entered into the patient's chart after being reviewed by the privileged clinical staff/physician and initialed by same, but before interviewing the patient during the initial assessment. The physician then discusses plans for the need for more intensive assessment; whether conducted or facilitated by this organization based on its scope of services or the patient is referred to another level or specialty of care. This is based on the care, treatment and services sought; the patient's presenting condition(s) and whether the patient agrees to care, treatment, and services or there is a conflict. 
 All significant testing, i.e. laboratory, radiological, other diagnostic results, that have been requested by the physician 
based on examination are entered into the patient's chart after being reviewed and initialed by the ordering physician 
or another privileged provider. If the procedure will occur within this organization, the physician will also discuss the procedure/surgery, anesthesia, and risks, benefits, and alternatives to treatment and/or procedure/surgery and as appropriate the risks, benefits, and alternatives to anesthesia.  
 
Reassessment Procedure 

Reassessments occur when the patient's needs change and/or on information obtained from diagnostic procedures, laboratory findings, etc, the patient's response to care, treatment and services, a significant change in status/condition or diagnosis, the patient's desire for care, treatment, or services changes, or legal or regulatory requirements. 
Reassessment also occurs prior to surgery and post operatively. Post procedure follow up visits are made for the  
patient either during the preoperative/pre-procedure phase or on discharge from the organization on the day of the 
procedure/surgery.At all times the patients needs, strengths, limitations, and goals are considered during assessment and reassessment and the plan of care is individualized to meet each patient's needs.

Approved By Governing Board    
GE.5    
Control #322.6
Gupta Gastro