Patient Profiling and Assessment, Essay Example

Patient profiling and assessment are incredibly important aspects of the care process in a clinical setting, especially for new patients entering a given clinical system for the first time. This is, so to speak, the “I like New York in June, how about you?” phase of the clinician-patient relationship and it is an extremely important one.  The information gathered in this phase will give the clinician the information he or she needs to start formulating a plan of care based on individual needs, and is the beginning of the rapport that will ideally be established between the patient and clinician as well. This paper talks a little bit about the profiling and assessment that takes place at our clinic and about modifications that can be made to this process to target specific patient needs.

The Profiling and Assessment Process at Our Clinic

I work at a busy family practice clinic in Okemos, Michigan, and the profiling and assessment phase for patients at our clinic is pretty straight-forward.  Patients entering our system fill out an extensive health information form.  This form begins with a section for contact information, insurance information, HIPPAA disclosures, and the like.  The medical section of the form seeks information on current and past medical conditions, surgical history, current medications (prescriptions, over the counters, herbs, vitamins, supplements and topical medications), family medical history, and information on drug/food/environmental allergies.  We also, as sensitively as possible, ask for information of patient background like their racial/ethnic background, religious preferences if any, age, marital/family status, education, etc., since all these factors can influence the plan of care.  Lastly, we get information from the patient on what is the reason for their visit today and what are the primary health concern that have brought them to our clinic. This is all entered into the patient’s electronic health record.

Modifications to this Process for Particular Patient Conditions

The patient in this theoretical situation is obese and a smoker.  There could be a number of modifications that could be made to the profiling/assessment process to address potential health problems due to tobacco use and weight issues.  Assessment for smoking is incredibly important, as it has been shown that “the act of asking patients about their smoking status increases smoking cessation….it has been reported that the probability of remaining abstinent after one year is higher among people whose physicians advised them to quit” (Nwai, 2010, p. 3).  In a guide for nurses for assisting their patients to quit, the Tennessee Department of Health recommended asking patients about their tobacco use at every visit and recording it with vital signs; they also recommended actions like advising patients to quit or helping them to determine the barriers to quitting, assessing readiness to quit and assisting with a smoking cessation plan if the patient is ready; in addition, they recommended follow-up visits to see how the plan is working (Tennessee Department of Health, 2011, p. 4).  All of these actions would be good to help this patient quit smoking.  Certainly if this patient came into my office, I would include a detailed respiratory exam as part of his assessment and a detailed smoking history so I understand precisely what challenges the patient is facing in regards to smoking cessation.

The assessment and discussion of the patient’s obesity is a little harder, because, as Dr. Kushner, writing for the American Heart Association, notes, “few other conditions in medical practice…are as stigmatized and shunned as obesity” (Kushner, 2012, p. 871) and recommends that obesity be seen as “a complex disease caused by genetic, biological, economic, environmental, psychosocial, and behavioral determinants” (p. 875).  Even if this topic is very sensitive, though, it is important to have the discussion about weight with your patient and it is recommended that the assessment be “focused on weight history, evaluation diet and physical activity, assessment of the patient’s readiness to lose, and the determination of achievable goals and treatments” (Bessesen, 2010, p. 196).  Kushner is even more specific and talks about the importance of also assessing obesity history (finding out what has triggered weight gain at different points in the patient’s life), screening for mood or anxiety disorders, and assessing the patient’s motivation and support system for weight loss, the constraints of time or money the patient might be facing (Kushner, 2012, p. 876).  All this goes to show that the better you as a clinician know where patient, the more likely it is that you will be able to treat them with some degree of access and improve their outcomes in a significant way.  If the patient in this example were able to lose weight or quit smoking because of our clinical efforts beginning with his profiling and initial assessment, this of course would be a tremendous boon for the patient.

Conclusion

Thus it is easy to see why the profiling and assessment phase of nursing care is so important, particularly for new patients entering into a given clinical setting. Taking the time to  understand the patient and what physical, emotional, and background issues they are bringing in with them is key to forming a plan of care that is relevant, will be utilized by the patient, and will promote the best patient outcome possible.  That is why modifying profiling and assessments to fit the individual needs and health concerns of the patient are so important: there is no effective “one size fits all” approach to thorough assessment, and without this thorough assessment, the rest of the care plan falls apart.

References

Bessesen, D. (2010). Assessment of the Obese Patient.  Contemporary Endocrinology. (24) 3 195-213.

Kushner, Robert F. (2012).  Clinical Assessment and Management of Adult Obesity. Circulation (Journal of the American Heart Association). 126 (6) 870-877.

Tennessee Department of Health. (2011). Helping Smokers to Quit: A Nurse’s Guide.  Tennessee Department of Health Website. Retrieved from http://health.state.tn/DOWNLOADS/TQL_nursesguide.pdf

Nwai, N. (2010). Physician Assessment of Patient Smoking in Indonesia: A Public Health Priority. National Institute of Health.  Retrieved from www.ncbi.alm.nih.gov/Pmc/PMC2598505