The initial assessment is actually the first opportunity in the note to demonstrate case management. It’s here that we peek into the doctor’s thoughts about their rationale for treatment options and how the patient will likely respond to care. It’s here that we outline how this patient may be different from others with similar diagnoses or conditions. Prognostic factors such as type of work, psycho-social factors and emotional state, previous episodes, and lifestyle habits can affect one patient differently from another. The assessment is the place that a third-party reader will understand this patient’s unique presentation and circumstances.
Elaborate on the assessment with documentation of your diagnosis and treatment plan in detail to really make it shine! When using a paper documentation system, add this information to the treatment plan, or on a separate sheet of paper to include with initial documentation. Here is an example of a simple, straightforward assessment:
“Based on the information available, I believe that Mrs. Jones is suffering from cervical radiculitis. Her case is complicated because she is of advanced age and her fall down seven stairs was traumatic, which will likely result in slower response to care. There are no obvious contraindications to beginning conservative care. A trial of care will be initiated for four weeks, and she will be seen three times per week until she is re-evaluated. The goal of treatment is to bring her grip strength in her left hand from 8kg (poor) to 22 kg (WNL) within this time frame. Her progress will be monitored closely and changes will be made as necessary.”
Strive to customize the initial assessment and their unique situation for maximum effectiveness in your documentation.