Observations to include in a Care Plan, Review & Health Assessment

Jane Calligeros, Founder & CEO CDM Plus

Chronic Disease Management activities include Care Plans, Reviews and Health Assessments.  Each of these activities have different requirements and this can sometimes be a bit overwhelming for clinical staff working in primary healthcare.

A lot of the information that a Nurse or Health Worker will collect during an appointment for a Care Plan is almost identical to the information in a Health Assessment:

  • Updating Patient Details (Family/Social/Medical/Surgical History)
  • Recording Observations
  • Reviewing Medications
  • Reviewing Last Bloods
  • Reviewing Specialist/Allied Health & Other Program involvement
  • Document Prevention and Detection activities
  • Documenting Recommendations

The Observations you record for each patient will be slightly different depending on the age, the patient conditions and the CDM activity you are completing.  We’ve provided you with a table to help simplify which observations to record for Care Plans, Reviews & Health Assessments.

Observations to Record for Care Plans, Reviews & Health Assessments
ALL Conditions and Health AssessmentsSpecific ConditionsSpecific Health Assessments
Blood Glucose LevelBlood PressureHeart RateECG (within last 12 months)Visual Acuity (within last 12 months)Height/Weight/BMI/WaistUrinalysisRespiratory Rate (Respiratory Conditions)Oxygen Saturation (Respiratory Conditions)Peak Flow (Respiratory Conditions)Point of Care Testing (HbA1c/ACR) (Diabetes/CKD)Heart Rhythm (ATSI 55+/>75yr/RACF)Audiometry (ATSI 15-54 yrs/Intellectual Disability)Neonatal Hearing Screening & Audiometry (ATSI 0-14 yrs) 

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