Assessment
Assessment questions test whether you can gather valid data from a person whose communication, cooperation, and history differ from the general population - and whether you can recognize an incomplete assessment. The exam favors systematic, baseline-anchored, multi-source assessment over one-time impression.
Principles
- Establish and use a baseline. Without a documented usual state, "change" cannot be detected. Record the personal best and usual pattern, not just today's findings.
- Use multiple informants. The person, family, direct support staff, day program staff, and previous records each contribute. Inconsistency between informants is data, not noise.
- Adapt technique. Allow extra time; use simple, concrete language; offer visual supports; assess in a familiar place; observe function (what the person actually does) rather than relying on self-report alone; involve a trusted support person without letting them answer for the person.
- Screen for the hidden problems in this population: constipation, dental pain, reflux, sleep disturbance, untreated pain, vision and hearing deficits, medication side effects, and abuse or neglect.
- Use structured risk tools where the agency uses them - for example, health risk screening instruments that rank mortality and morbidity risk and trigger nursing follow-up - and reassess when condition changes.
- History matters. Birth history, seizure history, prior hospitalizations, allergies, current medications (including over-the-counter and PRN), and guardianship or decision-making status belong in every assessment.
Worked example
A 30-year-old with autism and limited verbal communication is brought to the clinic for a wellness visit; staff report "more screaming." A complete assessment obtains the onset and pattern of the screaming, sleep and bowel records, a medication review, an oral exam, an observational pain assessment, and a report from the day program. The nurse also checks hearing and vision status, since both are commonly under-diagnosed. The conclusion, once ear pain and constipation are ruled out, is far more defensible than either "behavior" or an immediate psychotropic referral.
Traps
- Relying on a single informant or a single visit.
- Accepting " nonverbal, so unable to assess" - assessment is adapted, not abandoned.
- Missing atypical presentations: infection without fever, cardiac symptoms without chest pain.
- Failing to reconcile medications or to ask about PRN and over-the-counter use.
- Recording conclusions ("comfortable") instead of data ("ate 75% of lunch, guarded abdomen when repositioned").