See also: Assessments
Assessment > Health Assessment (via the Clinical Window)
Health Assessments are only available for patients over the age of 75 years (55 years for Aboriginal and Torres Straight Islanders). Health Assessment templates are also available via Letter Writer.
From within
the Clinical Window, select
Assessment >
Health Assessment.
The Health
Assessment window is displayed.
You must obtain the patient's consent to perform a Health Assessment.
After obtaining consent, enable the associated option and then
click Next
when you are ready to continue.
The
Demographics
window appears. The Demographics window displays the patient's
demographic details and prompts for living details, medical history
and family history. This window will display data from the patient's
Past History and Family History, and can be added to using the
options and check boxes provided, or by free-typing text into
the available text boxes.
Click
Next when
you are ready to continue. The Social/Other
History window appears.
This window displays information about the patient's social history
including smoking status, diet, and exercise details. Enter data
as necessary.
Click GDS (Geriatric Depression Scale) to diagnose and manage depression by indicating the probability of depression based on the results of a set of structured questions.
Click MMSE (Mini Mental State Examination) to help assess the probability of cognitive impairment based on the results of a set of structured questions.
Click
Next when
you are ready to continue. The Preventive
Medicine window appears. This displays previous Influenza,
Pneumovax and Tetanus vaccinations,
Mammograms and Cervical Screening.
Make recommendations as necessary.
Click
Next when
you are ready to continue. The Examination
window appears. Enter data and recommendations as necessary.
Click
Next when
you are ready to continue. The Activities
for Daily Living window appears. Record how well the patient
is able to perform daily activities. For each activity listed,
select if they can perform it normally, with slight impairment
or with severe impairment. Make recommendations as necessary.
Click
Next when
you are ready to continue. The Medication
Review window appears. This window lists the patient's
current medications and highlights potential problems. If necessary
you can perform a Medication
Review.
Click
Next when
you are ready to continue. The Recommendations
window appears. Add general recommendations as required.
Click
Next when
you are ready to continue. The Finished
window appears.
You must print the Health Assessment if you need a permanent record;
clicking the Save
button will only keep a record of the assessment for 14 days.
When printing, two copies of the assessment must be printed; one
for the patient and one for your own records. A copy of the assessment
will also be recorded in the patient's Letter
Writer database and a note that the assessment was conducted
is added to the patient's Progress
Notes.
Click Add Recall if you wish to record a Recall entry for the patient to return in 12 months to complete another Health Assessment.