43Meaning of health assessment

43 Meaning of health assessment

(1) For items 700, 702, 704 and 706, health assessment means the assessment of:

(a) a patient’s health and physical, psychological and social function; and

(b) whether preventative health care and education should be offered to the patient, to improve the patient’s health and physical, psychological or social function.

(2) A health assessment involves all of the following:

(a) a personal attendance by the medical practitioner;

(b) measurement of the patient’s blood pressure, pulse rate and rhythm;

(c) an assessment of the patient’s medication;

(d) an assessment of the patient’s continence;

(e) an assessment of the patient’s immunisation status for influenza, tetanus and pneumococcus;

(f) an assessment of the patient’s physical functions, including the patient’s activities of daily living and whether or not the patient has had a fall in the last 3 months;

(g) an assessment of the patient’s psychological function, including the patient’s cognition and mood;

(h) an assessment of the patient’s social function, including:

(i) the availability and adequacy of paid, and unpaid, help; and

(ii) whether the patient is responsible for caring for another person.

(3) A health assessment also includes:

(a) keeping a record of the health assessment; and

(b) offering the patient a written report about the health assessment, with recommendations about matters covered by the health assessment; and

(c) offering the patient’s carer (if any, and if the practitioner considers it appropriate and the patient agrees) a copy of the report or extracts of the report relevant to the carer.