Ongoing Assessment
Published: 25 June 2023
Published: 25 June 2023
Clients receiving aged care services typically do so for a length of time in which their health status may change or deteriorate.
In order for aged care providers to adjust to these changes and ensure clients are receiving an appropriate level of care, regular re-assessment of their condition, needs and goals is essential.
Ongoing assessment is a component of the Aged Care Quality Standards, Standard 2: Ongoing Assessment and Planning with Consumers.
Upon the commencement of the client’s care, providers should undertake an initial assessment in order to identify their needs and gain baseline data for the person.
The goal of assessment is to gain a multi-dimensional understanding of the client by exploring their medical, physiological, social and psychological functioning. By taking the time to thoroughly examine each aspect of the client’s life, you will be able to identify any issues, minimise risks and maximise their quality of life (Health.vic 2015).
The Victorian Department of Health has developed a template for conducting a comprehensive assessment of older adults in health and aged care. This assessment includes:
(Health.vic 2014)
Each of these assessments should be performed comprehensively. Further risk screening and assessment may also be completed during the initial assessment, such as a falls risk, malnutrition risk and pressure injury risk assessment. It’s important that each of these areas are also part of the ongoing assessment with the person.
Once care has commenced, the client should continue to be assessed on a regular basis in order to identify any changes in their condition, needs and goals.
Care providers should have regular conversations with their clients in order to determine the appropriate level of care required for each individual. The goal of these discussions is to:
(DoHaAC 2020)
The following topics should be discussed in these conversations:
(DoHaAC 2020)
The results of these discussions should be documented in the client’s agreements (DoHaAC 2020).
Your organisation may use some of the following documentation in order to maintain information about clients and their needs:
(Quality Aging n.d.)
Your facility may utilise a ‘resident of the day’ program to assess whether each client’s needs are being appropriately met. Generally, each client would be reviewed at least every month (Quality Aging n.d.).
When conducting reassessment, you may notice that the client is eligible for additional funding under the Australian National Aged Care Classification (AN-ACC).
When assessing a client’s needs, it is important to keep the following in mind:
(Health.vic 2015)
When conducting assessments, it’s important to consider the elements of effective clinical decision-making:
(Health.vic 2014)
Therapeutic communication involves prioritising the client’s wellbeing by providing them with support and information while maintaining professional distance and objectivity. It comprises a range of techniques, including:
(Rivier University 2017)
Practising person-centred care is a key component of the assessment process, as clients should be empowered to actively participate in future planning and decision-making. Clients should be provided with adequate information and opportunities to ask questions so that they can make informed decisions about the direction of their care. Utilising person-centred care improves client satisfaction and the quality of the services delivered (ACSQHC 2019; Better Health Channel 2015).
The ongoing assessment of clients’ needs is an essential component of care, as outlined in the Aged Care Quality Standards. In order to provide an appropriate level of care to all clients, it is important for care providers to work closely with clients to regularly discuss and evaluate whether the services being provided are adequate.
Question 1 of 3
True or false: The patient's goals should be included in a comprehensive initial assessment.