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Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
Medical social work is a sub-discipline of social work that addresses social components of medicine. [1] Medical social workers typically work in a hospital, outpatient clinic, community health agency, skilled nursing facility, long-term care facility or hospice .
A clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach to the more ...
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
Client assessment, medical results and diagnostic reports. This is the first step in order to be able to create a care plan. In particular client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age related, economic and environmental.
Psychosocial assessment considers several key areas related to psychological, biological, and social functioning and the availability of supports. It is a systematic inquiry that arises from the introduction of dynamic interaction ; it is an ongoing process that continues throughout a treatment, and is characterized by the circularity of cause ...
The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and ...
The assessment includes social and biographical information, direct observations, and data from specific psychological tests. It is typically carried out by a psychiatrist , but it can be a multi-disciplinary process involving nurses , psychologists , occupational therapist , social workers , and licensed professional counselors .