Title: Reading: (CU2 M5) The Assessment
Course: SkillsCom CMA 111 16.0 > Section: Credit Unit 2 Module 5

The Anatomy of Assessment

In order to properly understand the assessment portion of the chart note, it is necessary to understand the definition of the assessment as well as the difference between the assessment and problem.

Assessment means: the evaluation or estimation of the nature, quality, or ability of someone or something.  In our case this could refer to the patient, the disease, the treatment, etc.

When a problem is listed  in the problem list it is usually some derivation of the chief complaint or list of complaints provided by the patient.

For example:

1. The actual problems listed for a given patient, Fred, is foot pain, headache, and occasional dizziness.  This is what the patient explained to the MA while being room, and what the MA documented into the chart as “CC” for this visit.

1. This may or may not make it to the problem list “as is”.  In other words, Fred’s problem list may or may not contain the words “foot pain” or “dizziness”, but they absolutely have to be represented if these are to be considered as chronic problems with ongoing treatment over a medium to long-term period of time.

1. Next comes the “assessment” portion of the progress or SOAP note and it is important to use professional medical language to do one of the following:

  - make a first time diagnosis of a new problem
  - assess our treatment progress on an existing problem
  - assess or update our prognosis
  - assess or update our management treatment option

1. Now the chart note should reflect the assessment from #3  above.  Using Fred as an example….

  - Fred’s problems of foot pain, headache, and occasional dizziness may transform in the documentation of the assessment to gout and hypertension. Gout and hypertension may now replace those three problems on the problem list and gout and hypertension will be listed here as new diagnoses.
  - If Fred’s hypertension and gout are chronic problems that are already in the midst of a treatment program for……. rather than restating the problems, a progress (status) update on the treatment of each will be listed.  The words improving, worsening, resolving, etc may be used to describe the progress rather than just a listing or restatement of the already listed problem.
  - If a prognosis is requested or required for proper care and treatment of the patient’s problem, the assessment is where that should be placed.  Whether the problem is acute or chronic, both the patient, and other healthcare providers may want to know what the provider feels is the prognosis for the patient to progress in order to properly evaluate the effectiveness of the chosen treatment plan.
  - There may be a situation where a diagnosis is not possible given the education, experience, or data available to the current provider.  In this case, a diagnosis should not be documented, contrived, guessed, or conjured in any way.  However, options for further evaluation and management should be clearly laid out instead.
    - For instance, if after exam and history there is no idea what is causing the headache, the provider may want to order a cranial CT scan or refer the patient to neurology.  These would be two management treatment options that should be documented in lieu of a diagnosis.  In this case the problem must remain as the patient stated it until we have a definitive diagnosis.