ASSESSMENTSystematic evaluation using validated tools. Completed within required timeframes and when status changes. Documentation supports care planning. Required for accreditation compliance.
VITALSIGNSVitalsigns in healthcare practice involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
PHYSICALWe use the PIECES model (Physical, Intellectual, Emotional, Capabilities, Environmental, Social) and standardized assessments (e. , RAI-MDS) to capture a holistic view of the client's health. Documentation is maintained in the client health record/chart.
COGNITIVEA comprehensive assessment includes: reason for referral, medical/surgical history, current health status, functional abilities (ADLs/IADLs), cognitive status, mood and behaviour, social determinants of health, family/caregiver support, and client goals. Review assessment templates in your
PAINAssessment using validated scales at regular intervals and when status changes. Management includes pharmacological and non-pharmacological approaches. Documentation of intensity, location, interventions, effectiveness. Reassessment per protocol.
SKINWe ensure client-centeredness by involving clients in all care decisions, respecting their schedule preferences where possible, honoring cultural needs, and regularly asking for feedback on their care experience.
FUNCTIONALCriteria include: age range, geographic catchment, diagnosis/condition, functional level, and service needs. We assess safety, client willingness, and goal alignment.
DOCUMENTINGMy role includes conducting comprehensive assessments, developing person-centered service plans, providing skilled care, coordinating with the healthcare team, monitoring progress, and documenting care provided.
CHANGESWe notify the client as soon as possible, explain the reason, introduce the new coordinator, provide updated contact info, and have the new coordinator review the care plan with the client.
ONGOINGThis information is available on The Pulse intranet (The Pulse/PolicyMedical). Ethics issues are documented in client health record/chart. Documentation includes: description of ethical issue, who was involved in discussions, values/principles considered, options explored, decision reached
