Name of the Procedure:

Functional Outcome Assessment Documented as Positive Using a Standardized Tool, with a Care Plan Based on Identified Deficiencies

Summary

This procedure involves assessing a patient's functional abilities using a standardized tool, documenting the results, and creating a care plan based on any deficiencies identified. The goal is to understand the patient's current functional status and address any issues to improve their overall health and quality of life.

Purpose

This procedure is designed to evaluate a patient's physical, mental, and social functionality. It aims to identify areas where the patient may have deficiencies and to create a targeted care plan to address these issues. Expected outcomes include improved patient functionality and well-being.

Indications

• Chronic illnesses affecting daily living (e.g., arthritis, multiple sclerosis).
• Post-surgical recovery.
• Rehabilitation following injury or illness.
• Conditions impacting mental health (e.g., depression, anxiety).
• Age-related functional decline.

Preparation

• No fasting or specific medication adjustments required.
• Completion of pre-assessment forms detailing medical history and current symptoms.
• Any recent diagnostic tests or medical records should be provided to the healthcare provider.

Procedure Description

1. Initial Consultation: The patient meets with a healthcare provider to discuss medical history and current symptoms.
2. Standardized Assessment: The patient completes a functional outcome assessment using a standardized tool, which may include physical tests, questionnaires, or both.
3. Documentation: The results are documented, noting areas of positive functionality and deficiencies.
4. Care Plan Development: Based on the assessment results, a care plan is created, which may include physical therapy, occupational therapy, medical treatments, or lifestyle changes.
5. Follow-Up: Scheduled follow-up appointments to monitor progress and adjust the care plan as needed.

Duration

The initial assessment and care plan development typically take between 1-2 hours.

Setting

This procedure is usually performed in an outpatient clinic, rehabilitation center, or medical office.

Personnel

• Primary Care Physician or Specialist.
• Nurse.
• Physical or Occupational Therapist, if required.

Risks and Complications

• Minimal risks, primarily related to the accuracy of self-reported information.
• Rarely, physical tasks in the assessment could cause minor discomfort or fatigue.
• Misdocumentation due to human error, leading to inappropriate care plans.

Benefits

• Identification of functional deficits and strengths.
• Personalized care plan to address specific needs.
• Improved functional status and quality of life.
• Prevention of future complications through early intervention.

Recovery

• Immediate post-assessment instructions typically involve following the newly developed care plan.
• Patients are advised to adhere to prescribed therapies and attend follow-up appointments.
• Recovery time varies depending on the specific interventions and the patient's condition.

Alternatives

• No formal assessment, relying on standard clinical evaluations.
• Patient self-management without professional guidance.
• Single-discipline intervention (e.g., only physical therapy or only medication).

Pros of the Described Procedure:

• Comprehensive evaluation and targeted interventions.
• Alignment of care plan with specific patient needs. ##### Cons of the Described Procedure:
• Time-consuming.
• May require multiple healthcare visits.

Patient Experience

During the assessment, patients may feel engaged as they participate in evaluating their functionality. Some tasks might be physically challenging but are generally safe and well-tolerated. Post-assessment, patients usually feel more informed about their condition and motivated to follow the care plan. Pain management strategies and comfort measures are addressed within the care plan to ensure an optimal recovery journey.