Clinical

Assessment and Planning

Careful assessment and planning for treatment is vital for safe, effective and person centred care - the 3 quality ambitions in the NHSScotland Quality Strategy.

This means that, when thinking about assessment and planning processes, you need to draw on your full range of skills and knowledge, and think about the varied partnerships and settings involved in providing care.

How does my team assess patients or clients?

This activity can be split into 3 stages:

1.  As a newly qualified practitioner, you should familiarise yourself with the assessment and planning processes involved within your work setting.

2.  Initially, in discussion with your mentor, you may wish to be involved within the assessment and care planning process by observing your mentor or another experienced practitioner. This will help you understand the process and desired results before carrying it out yourself.

3.  Make sure that you and your colleagues are aware of the latest policy and research available on the links between health and work. You can find out more by linking to Good Work Good Health Managed Knowledge Network (MKN)

Building my assessment skills

Having gained an insight and overview of the assessment and planning processes within your work setting, you should now start to contribute to the process.

With your mentor, agree the role you will currently take in assessing, decision-making and planning treatment for a patient/client in your caseload.

You should review this role regularly as you develop your skills and identify where you can increase your contribution.

Multi-professional assessments

This activity can be split into 2 stages:

As you have seen in the previous activities in this section, making accurate assessments to base care on depends on information and data from a range of sources and professionals.

For your portfolio:

1.  List the assessment and planning processes used in your work setting by your team and the other teams you that have identified.

2.  Identify and record any duplications that you have found and the scope for multi-professional assessment in your clinical area e.g. Single Shared Assessment, Integrated care plans/pathways.

NES Information Governance Module

'Confidentiality and effective information handling are key components of professional practice for NMAHPs. These have a direct bearing on the quality of patient care and are taken seriously by your employer. Training for safe information handling is mandatory and most NHSScotland Health Boards have made an Information Handling in Practice e-learning module available to staff through their learning management system (learnPro or AT-Learn).'

You may have to complete or have completed NES Information Governance Module in your Health Board or elsewhere in Flying Start NHS®. If you have not, it will help to develop your knowledge and awareness of the issues around safe information handling. It takes around an hour to complete and can be completed in stages.

Safe-guarding information and confidentiality

In your role in providing patient/client care and team working you may have access to information about patients/clients and staff and will routinely use this in your daily work.

You need to remember that people legally have the right to expect that information about them will be held in confidence. This is governed by:

  • legislation e.g. the Data Protection Act (1998)
  • your professional regulator
  • NHSScotland policy
  • Health Board policies e.g. handling records, test results and specimens for testing.

You will have learned about your responsibilities in relation to confidentiality as an undergraduate and as part of your Health Board induction and now need to think about putting what you have learned into action in your new role.

Identify situations in your work where you need to be particularly aware of the potential for breaches of confidentiality and plan and reflect on how you can minimise the risks of errors. Discuss what you have identified with your mentor and make a portfolio entry detailing the risks and how they can be minimised.

Review the following resources to learn more about these issues in NHSScotland:

Your professional regulator and confidentiality

Building on the previous activity, review your professional responsibilities in relation to confidentiality.

NMC: Confidentiality page

HCPC: Confidentiality - Guidance for registrants

Reflect on how this fits with what you learned from in the resources in the previous activity.

Record the key points, similarities and differences with the information you looked at and your reflections on your responsibilities for your portfolio.

Developing your care/treatment planning skills

This activity can be split into 2 stages:

1.   As you progress through your first year, your caseload should increasingly include patients/clients who:

  • have increasingly complex assessments and care
  • have increased levels of interagency and inter-professional working

2.   You should discuss your caseload with your mentor and agree how to build in more complex cases to your workload.

Capacity and consent

This activity also appears in the Safe Practice unit - if you have completed it in that unit you may want to take some time to review what you learned from a clinical practice perspective here.

This activity requires you to critically examine the issues for your profession around capacity and consent from 2 perspectives:

1.    In relation to your practice (using information from your professional regulator)

2.    Using the interactive learning resource 'Think Capacity, Think Consent'.

As this will take around an hour and a half you may want to complete it in stages.

1. What your regulator says

Take time to review your professional responsibilities in relation to consent.

It is essential that patients/clients understand the implications and risks of the care and treatment they receive. You have a significant role in ensuring that they understand what is proposed, are aware of the potential benefits and risks and agree to the treatment or care taking place.

2. Think Capacity, Think Consent'

Now that you know what your professional regulator expects of you, you need to ensure that you can assess patient's/client's capacity to consent to treatment.

'Assessment of capacity to consent to treatment is an important legal and ethical issue for staff working in acute general hospitals. It is estimated that between 30% and 52% of people admitted to hospital will lack capacity to consent to treatment'.

This quote is from the NHSScotland 'Think Capacity, Think Consent' interactive learning resource. It is recommended that all NHSScotland staff who provide care and treatment complete the learning activities in this resource.

Care/Treatment Planning Scenarios

Below are six scenarios based in practice. Choose one which has resonance for you. Here are some suggestions to help you take this forward:

  • You could post a question on the Discussion Forum to stimulate professional debate
  • You could post a question on the 'Ask an Expert' question and answer topic
  • You could work through the selected scenario with a peer group
  • You could write it up and put it in your portfolio

Scenario 1

A patient/client has a hearing impairment and you are finding it difficult to complete a full assessment on them. What resources are available within your local and national areas? Who could you involve from the multi-professional team to help you pass this information to the patient/client?

Scenario 2

You have completed an assessment on your patient/client and have identified a problem which needs to be referred to another agency. However, you have never referred to this agency before and you do not have any documentation or contact details for them. How will you find out what needs to be done and what your role could be?

Scenario 3

You have visited a patient/client in their own home and are concerned about their mental health. You conclude that the patient/client could be a danger to themselves. What will you do? What other multi-professional groups need to be involved?

Scenario 4

You are concerned about the safety of an older gentleman as you feel that he can no longer look after himself at home. However he refuses any further help from social services. What do you document in your assessment of the situation? What other resources and/or professionals might you use?

Scenario 5

You have assessed a pregnant woman and you are concerned about the growth of her baby. She asks you if everything is alright. What information will you pass on to her? Are there other professionals that could be used to help you further assess this woman and perhaps tell her of your concerns?

Scenario 6

A patient/client is assessed as almost ready for discharge from secondary care to living independently at home. What factors should be considered in order to facilitate a safe transition to home?

Portfolio - assessment and planning skills

This activity can be split into 2 stages:

1.  Using the information you have collected as part of the activities in this section, identify the assessment and planning skills that you need to develop in order for you to carry out your post safely and effectively. Go over these with your mentor to ensure that your assessment reflects the work that you are expected to do.

2.  With your NHS KSF reviewer agree how these needs fit into your Personal Development Plan for the next 6 months.

Decide upon dates for reviewing your progress in this area with your mentor.

Add an alert to your Flying Start NHS® portfolio and /or make a date in your diary to revisit assessment and planning.