How can you assess patients effectively?

I guide patients on how to complete their own framework for me. It uses the 4 Pillars of Health of the Māori Model of Health (I’m in New Zealand): Physical, Psychological, Emotional (relationships) and Spiritual Health (connections and meaning and purpose in life). Let’s not forget that 30-50% of presentations to both primary and secondary care have no identifiable underlying pathology. The answer may lie in any of the 4 pillars. I take patients of their Hero’s Journey. This is the stocktake they do before setting off on their healing journey. Yes, I use my expertise as a doctor and diagnostician, but I teach them how to be the experts in their own health. I also ask them where their illness has come from. Often their answer is trauma.

I agree, but to move that communication to a trusting level I opine that it is important to also ensure that the patient and their loved ones understand the information that is being given to them.

You must meet the patient and their family where they are. Consider their comprehension level of medical speak, their cultural background, and their beliefs. You must respect the fact that they are the experts on their bodies even though you are the medical expert. You must communicate to the patient as if you are partners in their care because you are!

Communication is key to effectively assess clients; however using medical terms will confuse a client faster and that will cause a bigger issue. Being able to relay the medical information to a client in terms that they understand and encouraging them to bring someone for a second set of ears; is the best way to communicate with a client.

Accurate and easy-to-understand documentation is essential not only for you but for the patient as well. It can serve as a roadmap and a reminder of how far they have come on their health journey. The patient should have access at all times to their records. I have found Carepatron to be a very helpful and easy-to-use platform that allows secure HIPAA-compliant storing and sharing of documentation.

In the age now where patients can request access to their own medical record, clinicians should also make sure to write their documentation in a way that boosts the therapeutic relationship, is clear to understand, and includes the patient as a key driver in their own care.

There's a number of other things to consider - Consider the patient's overall health history and any pre-existing conditions that may affect their care needs. - Take into account the patient's cultural background, values, and preferences when making assessments and care plans. Ask questions to understand their perspectives. - Observe nonverbal cues like facial expressions and body language for additional insight into the patient's condition. - When possible, include family members or caregivers in discussions to get a more holistic view of the patient's status and needs. - Remain objective in your assessments. Avoid letting personal biases impact your evaluations and conclusions.