CCRP Patient Assessment
What is an Assessment? - answer An objective evaluation or
appraisal of an individual's health status,
including acute and chronic conditions
-the act of determining importance or value.
How does an assessment gather information? - answer through collection of data,
observation, and physical examination
**What Type of Assessment?
•Gather information about the patient from available sources such as medical records or
reports from diagnostic studies
• Perform direct measurements on the patient such as 12-lead EKG, blood pressure, or
body mass index - answer Objective assessment
**What type of assessment?
• Conduct standardized tests, such as a
12-lead EKG or a 6 minute walk test
• Observe patient responses or reactions such as cardiac rhythms on telemetry, oxygen
saturation on pulse oximetry - answer objective assessment
**In what type of assessment does the patient provide the information, usually as
solicited by practitioner - answerSubjective assessment
**What type of assessment does the patient?
• Describe their cardiac event
• Rate their level of pain or exertion - answerSubjective assessment
**What type of assessment does the patient?
• Report on recent behavior, eg, diet,
smoking, exercise
• Evaluating their own status by completing surveys - answerSubjective assessment
At the time of program entrance and exit, all patients should undergo or have the
following current screening and assessments: - answer• Current medical history -
medical or surgical profile (or both), including complications, comorbidities, and other
pertinent medical history
• Physical examination - cardiopulmonary
systems assessment and musculoskeletal
assessment, particularly upper and lower
extremities and lower back
• Resting 12-lead electrocardiogram
, • Current medications, including dose and
frequency
• Cardiovascular disease (CVD) risk profile
Per Joint Commission :The goal of an__________ is to determine the care, treatment,
and services that will meet the patient's initial and continuing needs. Identifying and
delivering the right care, treatment, and services depends on the following three
processes . . . - answerassessment
1. Collecting information about the patient's health history as well as physical,
functional, and psychosocial status
2. Analyzing the information in order to understand the patient's needs for care,
treatment, and services
3. Making care, treatment, and services decisions based on the analysis of information
collected
What is a problem/needs list used for? - answerCompleting a list of problems/needs
from the assessment analysis is the first step in creating an ITP.
**What is individualized case management? - answeris an integrated disease-
management process that provides specific risk factor intervention strategies. The
patient is the center of the process and takes an active role.
**What belongs to case manager? - answerThe _____________ responsibility is to
follow patient through from initial assessment to planning of interventions, to
reassessment, and discharge.
-Identify areas that can be impacted by rehab services to help improve patient's health
status and also to identify the way care should be delivered (items that may require
treatment changes or modifications
**Initial assessment has several purposes, name four: - answer•Confirm referral
diagnosis - it is not enough for a health care provider to scribble a diagnosis on a
prescription pad or to type it onto an electronic referral sheet; that diagnosis must be
confirmed by an official medical document to justify patient enrollment in rehab and
subsequent payment for services rendered
• Collect baseline data - each patient's starting point is verified through a series of facts
and figures about their status
• Begin risk stratification - information gleaned from activities comprising this first
encounter may provide clues to the likelihood of a recurrent cardiac event
• Build rapport with the patient - spending time with and showing a caring attitude
toward a new patient sets the stage for all staff: patient encounters that follow during
rehab
What is an Assessment? - answer An objective evaluation or
appraisal of an individual's health status,
including acute and chronic conditions
-the act of determining importance or value.
How does an assessment gather information? - answer through collection of data,
observation, and physical examination
**What Type of Assessment?
•Gather information about the patient from available sources such as medical records or
reports from diagnostic studies
• Perform direct measurements on the patient such as 12-lead EKG, blood pressure, or
body mass index - answer Objective assessment
**What type of assessment?
• Conduct standardized tests, such as a
12-lead EKG or a 6 minute walk test
• Observe patient responses or reactions such as cardiac rhythms on telemetry, oxygen
saturation on pulse oximetry - answer objective assessment
**In what type of assessment does the patient provide the information, usually as
solicited by practitioner - answerSubjective assessment
**What type of assessment does the patient?
• Describe their cardiac event
• Rate their level of pain or exertion - answerSubjective assessment
**What type of assessment does the patient?
• Report on recent behavior, eg, diet,
smoking, exercise
• Evaluating their own status by completing surveys - answerSubjective assessment
At the time of program entrance and exit, all patients should undergo or have the
following current screening and assessments: - answer• Current medical history -
medical or surgical profile (or both), including complications, comorbidities, and other
pertinent medical history
• Physical examination - cardiopulmonary
systems assessment and musculoskeletal
assessment, particularly upper and lower
extremities and lower back
• Resting 12-lead electrocardiogram
, • Current medications, including dose and
frequency
• Cardiovascular disease (CVD) risk profile
Per Joint Commission :The goal of an__________ is to determine the care, treatment,
and services that will meet the patient's initial and continuing needs. Identifying and
delivering the right care, treatment, and services depends on the following three
processes . . . - answerassessment
1. Collecting information about the patient's health history as well as physical,
functional, and psychosocial status
2. Analyzing the information in order to understand the patient's needs for care,
treatment, and services
3. Making care, treatment, and services decisions based on the analysis of information
collected
What is a problem/needs list used for? - answerCompleting a list of problems/needs
from the assessment analysis is the first step in creating an ITP.
**What is individualized case management? - answeris an integrated disease-
management process that provides specific risk factor intervention strategies. The
patient is the center of the process and takes an active role.
**What belongs to case manager? - answerThe _____________ responsibility is to
follow patient through from initial assessment to planning of interventions, to
reassessment, and discharge.
-Identify areas that can be impacted by rehab services to help improve patient's health
status and also to identify the way care should be delivered (items that may require
treatment changes or modifications
**Initial assessment has several purposes, name four: - answer•Confirm referral
diagnosis - it is not enough for a health care provider to scribble a diagnosis on a
prescription pad or to type it onto an electronic referral sheet; that diagnosis must be
confirmed by an official medical document to justify patient enrollment in rehab and
subsequent payment for services rendered
• Collect baseline data - each patient's starting point is verified through a series of facts
and figures about their status
• Begin risk stratification - information gleaned from activities comprising this first
encounter may provide clues to the likelihood of a recurrent cardiac event
• Build rapport with the patient - spending time with and showing a caring attitude
toward a new patient sets the stage for all staff: patient encounters that follow during
rehab
