Apprenticeship Learning Log
Date of Learning: 05/03/2025
Time: 9:30 – 16:30
Title of learning activity: Comprehensive Patient Assessment.
Clinical judgement and shared decision making.
Diary of Learning activity
(itemise learning activity and reflect on the main points of learning from each. You should identify for each entry the relevant KSB)
Reflection on Learning Activity (include model of reflection e.g. Driscoll or Gibbs):
On today’s session we were able to interact in group activities in Comprehensive patient assessment, clinical judgement and shared decision making. Considering certain scenario:
Harriet used to be a healthy child, never missed a day at school. Unfortunately, due to increasing numbers of pupils developing chest infection, Harriet has been admitted to the hospital with suspected chest infection. Based on given information’s our goal was to assess the patient, make a clinical judgement and care plan. Considering shared decision making.
Comprehensive Patient Assessment (CPA) is a holistic, systematic process that evaluates the physical, psychological, social, and functional aspects of a patient’s health. It goes beyond symptom-checking to understand the full picture of a patient’s needs, supporting safe, personalised, and effective care.
Key Components of CPA:
- History Taking – including medical, surgical, medication, family, and social history.
- Physical Examination – systems-based, tailored to presenting complaints.
- Mental Health Assessment – mood, cognition, behaviour, and risk factors.
- Functional Assessment – activities of daily living (ADLs), mobility, and support needs.
- Social and Environmental Factors – home situation, carers, safeguarding, and socioeconomic status.
Clinical Judgement, refers to the cognitive process used by healthcare professionals to evaluate information, consider alternatives, and make informed decisions about patient care. It draws on knowledge, experience, guidelines, and evidence-based practice.
Elements of Clinical Judgement:
- Pattern recognition (based on experience)
- Analytical reasoning (especially in complex or unfamiliar cases)
- Use of clinical guidelines (e.g. NICE guidelines)
- Awareness of biases and uncertainties
- Risk assessment and prioritisation
Clinical judgement is critical in:
- Escalating care (e.g. NEWS2 scores)
- Prioritising referrals
- Balancing benefits vs risks of interventions
- Safeguarding decisions
Shared decision-making (SDM) is a collaborative process where patients and healthcare professionals make health decisions together, considering clinical evidence and the patient’s values, preferences, and circumstances.
Principles of SDM:
- Respect for autonomy
- Clear communication of risks, benefits, and options
- Use of decision aids (e.g. NHS SDM tools)
- Patient empowerment through education and support
- Documenting decisions and reasoning
Benefits of SDM:
- Improved patient satisfaction
- Better adherence to treatment plans
- Reduced decisional conflict
- Enhanced health outcomes
Integrating CPA, Clinical Judgement, and SDM
In practice, these three elements interact as follows:
- CPA provides the data — gathering a full understanding of the patient’s condition and context.
- Clinical judgement interprets the data — applying knowledge to identify priorities, diagnoses, and interventions.
- SDM involves the patient — ensuring care is tailored to the individual’s goals and preferences.
Example in Practice:
Child (Harriet) admitted to the hospital with suspected chest infection.
Healthcare Professional action.
- Conducts a comprehensive assessment (physical exam, meds review, home risks).
- Uses clinical judgement to link hypotension and medication side effects.
- Engages in SDM with the patient and family to adjust the care plan, including community support and therapy referrals.
Comprehensive patient assessment, supported by sound clinical judgement and underpinned by shared decision-making, is fundamental to delivering high-quality, person-centred care. This approach aligns with NHS values of compassion, partnership, and respect for individual dignity.
KSBs addressed:
K11: Understand the factors that may lead to inequalities in health outcomes
K13: Understand the contribution of social influences, health literacy, individual circumstances, behaviours and lifestyle choices to mental, physical and behavioural health outcomes
K21: Understand co-morbidities and the demands of meeting people’s holistic needs when prioritising care
S2: Keep complete, clear, accurate and timely records
S3: Recognise and report any factors that may adversely impact safe and effective care provision
S10: Provide, promote, and where appropriate advocate for, non-discriminatory, person-centred and sensitive care at all times, reflecting on people’s values and beliefs, diverse backgrounds, cultural characteristics, language requirements, needs and preferences, taking account of any need for adjustments
S18: Apply knowledge, communication and relationship management skills required to provide people, families and carers with accurate information that meets their needs before, during and after a range of interventions