Assessment

The process of evaluating a person’s needs, wishes, strengths and preferences, as well as identifying any relevant risks associated with them.

Assessments are performed for the Subject of care and can be expressed by a Proxy for subject of care if the Subject of care does not have Mental Capacity.

Care Actors perform, complete and authorise Assessments of the:

of the Subject of care.

Needs, Risks, Safeguarding concerns, Strengths, Wishes and Preferences are recorded during Assessments as Observations in reference to the Subject of care. These Observations about the Subject of care influence both assessment and care planning processes and are recorded before, during and after Assessments.

Care Needs Assessments evaluate the Needs, Strengths, Wishes, Preferences of the Subject of care. Needs include information about the significance and urgency of the care need and/or associations with 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 Care Actors the risks involves and if the Subject of care has 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 Assessment records should include a reference to the location of the Document containing the mental capacity assessment information.

Assessment records should include details about a scheduled Review.

Note: Financial Assessments are currently out-of-scope for the current iteration of the Adult Social Care Record.