Health Assessment

 

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.

 

1.      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 when you are ready to continue.

 

2.      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.

 

3.      Click 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.

o       Click the (Geriatric Depression Scale) button to diagnose and manage depression by indicating the probability of depression based on the results of a set of structured questions.

o       Click the (Mini Mental State Examination) button to help assess the probability of cognitive impairment based on the results of a set of structured questions.

 

 

4.      Click 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.

 

5.      Click when you are ready to continue. The Examination window appears. Enter data and recommendations as necessary.

 

6.      Click 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.

 

7.      Click 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.

 

8.      Click when you are ready to continue. The Recommendations window appears. Add general recommendations as required.

 

9.      Click 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.

o       Click if you wish to record a Recall entry for the patient to return in 12 months to complete another Health Assessment.