Assessment

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

Open

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:

• Needs

• Risks

• Safeguarding concerns

• Strengths

• Wishes

• Preferences

• and Mental Capacity

of the Subject of care.

Needs, Risks, Safeguarding concerns, Strengths, Wishes and Preferences are recorded as Observations in reference to the Subject of care 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.

The Adult Social Care Record (MODS) defines three typical types of assessments:

• Care Needs Assessments

• Risk Assessments

• Mental Capacity 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 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, any Care Actors that the Risk involves and whether 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.

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 where the mental capacity assessment is recorded.

Assessment records should include details about the scheduled Reviews.

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