Assessment > Health Assessment (via the Clinical Window)
See also Assessments
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.
within the Clinical Window, select
Assessment > Health Assessment.
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.
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.
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.
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.
when you are ready to continue. The Examination
window appears. Enter data and recommendations as necessary.
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.
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.
when you are ready to continue. The Recommendations
window appears. Add general recommendations as required.
when you are ready to continue. The Finished
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.