LO1 Follow an evidence-based protocol, obtain and document subjective health data that includes patient profile, presenting / chief complaint, history of present illness, past medical history, family medical history and social history.

Level 6 Assessment Brief

Assessment brief including criteria mapped to learning outcome

Learning outcomes to be achieved

• L.O1   Follow an evidence-based protocol, obtain and document subjective health data that includes patient profile, presenting / chief complaint, history of present illness, past medical history, family medical history and social history.
• L.O3   Describe and document a normal assessment of physical, social and mental status findings within each body system, using appropriate medical terminology. Relate principles of anatomy and physiology to the assessment process.
• L.O4   Recognize key signs and symptoms in common patient presentations.
• L.O5   Demonstrate the ability to communicate findings in verbal and written communication with professional colleagues

Step 1: Initiating the session:

Explore not describe how you prepared the area and the patient for the consultation; justify your approach, evaluate its effectiveness. Consider environment/privacy and dignity/consent/equipment/infection control. How as the clinician did you prepare, did you read the notes? 

What is the importance of introductions, rapport, communication skills- open and closed questions, positioning? Listening skills.

Step 2: Gathering information (insert ‘documentation of history taking’ table): use the subjection portion of the SOAP note