UNDERSTANDING ASSESSMENT AND DIAGNOSIS

 

Assessment

When a patient is admitted to a healthcare facility, the medical
staff is responsible for doing an assessment so a diagnosis can
be made.

Scenario: In the scenario above, Mrs.G is admitted to the hospital
with complaints of headaches and poor coordination for the last
two weeks. The nurse takes a history and does an assessment. She 
documents her findings.

Diagnosis

The doctor examines Mrs.G and makes a diagnosis based on the
nature of the complaints. He plans to run some tests, in order to 
confirm the diagnosis. The care plan will reflect the problems 
associated with diagnosis and treatment. It is updated daily or as
changes are made by the doctor.