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Needs, Risks, Safeguarding concerns,Strengths, Wishes and Preferences are recorded during Assessments as Observationsin referenceto the Subject of care. These during an Assessment. Observations are recorded before, during (and after) Assessments. Observations about the Subject of care made before the Assessment should be available during the Assessment as they can influence both assessment and care planning processes and are recorded before, during and after Assessments..
The Adult Social Care Record (MODS) defines three typical types of assessments:
Care Needs Assessments evaluate the Needs,Strengths, Wishes, Preferences of the Subject of care. Needs include information about the significanceand urgency of the care need and /or associations with can include a reference to a list of healthcare problems. Strengths, Wishes, Preferences are evaluated and recorded as a narrative description.
Risk Assessments identify Risks and Safeguarding concerns, as well as recording the reason for the risk assessment, the other any Care Actors that the risks Risk involves and if whether theSubject of carehas an understanding of the risks. Risks can include information about trigger factors, relapse indicators and information about the Care Actors who should be informed of the risk.
Mental Capacity Assessments, includes a narrative of whether an assessment of the mental capacity of the Subject of care has been undertaken. The narrative statement includes what capacity the decision relates to, the outcome of the assessment and the best interest decisions if person lacks capacity. Mental Capacity Assessmentrecords should include a reference to the location of the Document containing where the mental capacity assessment informationis recorded.
Assessmentrecords should include details about a the scheduled Reviews.
Note: Financial Assessments are currently out-of-scope for the current iteration of the Adult Social Care Record.
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