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The key function of clinical assessment is to identify a patient’s health status and needs. This is achieved through a systematic process of gathering information about the patient’s:
Symptoms: What the patient is experiencing (e.g., pain, fatigue, mood changes)
Medical history: Past health conditions, surgeries, medications
Mental health history: Past diagnoses, current mental health concerns
Family history: Risk factors for certain conditions
Lifestyle habits: Diet, exercise, sleep patterns
Social environment: Relationships, work, stress levels
By collecting this comprehensive data, a clinician can:
Diagnose any underlying medical or mental health conditions
Develop an appropriate treatment plan based on the patient’s individual needs
Monitor the patient’s progress over time and adjust the treatment plan as needed