The process of evaluating a person’s needs, wishes, strengths and preferences, as well as identifying any relevant risks associated with them.
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Care Actors perform, complete and authorise Assessments of the Needs, Risks, Strengths, Wishes, Preferences, and Mental Capacity of the Subject of care. Needs, Wishes, Strengths, Preferences, Risks and Mental Capacity are recorded as Observations in reference to the Subject of Care and can form a part of the Assessment record, Care Plan record or Observations record. Assessment are performed for the Subject of Care and can be expressed by a Proxy for the Subject of Care if the Subject of Care does not have capacity.
Needs Assessments evaluate the Needs, Wishes, Strengths and Preferences of the Subject of care. Needs can include information about the significance and urgency of the care need as well as associations with a list of healthcare problems and further detail e.g. stage of the disease etc. Wishes, Strengths and Preferences are evaluated and recorded as a narrative description.
Risk Assessments identify Risks and Safeguarding Concerns, as well as recording why the assessment was conducted, who the risks involve and if the Subject of Care understands the risks. Risks can include information about trigger factors, relapse indicators and who should be informed.
Mental Capacity Assessments, include a narrative of whether an assessment of the mental capacity of the (adult) person has been undertaken, if so, what capacity the decision relates to and the outcome of the assessment. Also record best interests decision if person lacks capacity, as well as a reference to the Document and DoLS record if relevant.
Note: Financial Assessments are currently out-of-scope for the current iteration of the Adult Social Care Record.