All doctors, clinicians and nurses must inevitably become skilled in executing clinical assessments. As an incredibly important stage in clinical practice, they are used to produce a diagnosis for each given patient. However, there is naturally an awful lot to consider when undertaking a clinical assessment – not only must you seek to make the correct diagnosis, but also to ensure the wellbeing of the patients themselves. How could improved data technology enhance the patient experience and information gathered from a clinical assessment? We’ve compiled this example of clinical assessment using the latest data improvements in order to give you a better impression of what the future may hold…
A clinical assessment is a process intended to determine the nature and severity of a patient’s illness. As such, there are numerous ways in which one must assess the patient at hand. Naturally, there are certain healthcare complaints that can be adequately assessed visually without recourse to other, more complicated techniques. Certain injuries, for example, can be easily assessed on sight – providing the healthcare professional with an adequate idea of the nature, cause and effects of the injury itself. Certain illnesses, infections and diseases can likewise be assessed by eye. Often, the transcription of complaints can be long and arduous. In the future, we’d expect more healthcare providers to make use of
Gather more data
There’s far more to the clinical assessment processes than visually determining the problem alone, however. In many instances you’ll need significantly more data to make an accurate diagnosis while offering the appropriate levels of care and most effective course of treatment for your patients. Communicating effectively with your patients will help you to gather much of this data, so it’s important to ask your patients as much as you can about the nature of their illness or injury. Determining how a healthcare problem came about can help you to identify any potential additional problems or ill effects down the line. Therefore you need to be aware of a patient’s medical history, how long they’ve been experiencing their symptoms, whether they’ve experienced similar complaints before and whether they’re otherwise healthy in the other aspects of their lives. Some healthcare problems can be highly complex and have their root in a variety of contributing factors, such as mental illness, poor health or socioeconomic deprivation, so there’s a lot you need to consider.
Clinical assessments aren’t purely a case of assessing healthcare complaints and determining an appropriate course of treatment, however. Patients are more than problems that need fixing, so it’s important that you take the time to administer to their wellbeing, too. Could you be doing something in the meantime to make them more comfortable? Could you impart any advice or instructions to help them manage their healthcare complaints themselves at home? All of these additional needs must also be considered during a clinical assessment.
Make a diagnosis
The final stage in the clinical assessment process is to make a diagnosis and prescribe an appropriate course of treatment. Based on the data you’ve gathered from visually examining the patient, checking previous medical records and discussing the symptoms with the patient themselves, you should now be in a position to make an accurate diagnosis and provide the patient with the help they need along the line. Good clinical assessments, of course, rely on the availability of data – be it reference materials or digitised patient records. Our healthcare data capture solutions are designed to help improve the availability and quality of patient data, so contact us and find out more about how we can help.