Client Assessment: Getting to know your Client

Client Assessment: Getting to know your Client

Found In: Activities Articles Care Plans

The importance of assessment in residential care settings cannot be underestimated. It underpins the philosophical approach to person-centred care, an ideology that provides clients with greater control and responsibility regarding their own health and lifestyle.
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The importance of assessment in residential care settings cannot be underestimated. It underpins the philosophical approach to person-centred care, an ideology that provides clients with greater control and responsibility regarding their own health and lifestyle.

Related: Person-Centred Care Defined

Why Do We Need to Assess Clients?

Every client entering residential care should be given a comprehensive assessment to identify individual needs, preferences, and strengths. The assessment is undertaken by an interdisciplinary team and covers various aspects of their’ lives such as: physical, spiritual, cognitive, social, mental, and emotional.

Client assessments lead to informed decisions that impact on care planning, resources allocation and other services.

The assessment process determines the most appropriate and effective way to support clients. Assessment usually starts soon after admission, however it depends of the organization and availability of staff.

Benefits of Conducting a Client Assessment

  • Opportunity to get to know the client as an individual
  • Establish areas of potential risk
  • Ascertain a client’s preferences and needs
  • Acknowledgement of cultural, religious, and ethnic values
  • Advocate freedom of choice and independence

Who is involved in a Client Assessment?

A partnership between the interdisciplinary team and client is necessary to conduct a successful assessment.

Clients should be actively involved in their assessment as well as their family/ caregivers and close friends. In many organizations a case manager is assigned to support clients during the assessment process.

Leisure and Health staff are responsible for the Social/Spiritual Care Plan that includes recreation, relaxation, community trips, club affiliation, and other aspects of daily life.

Channels for Identifying Client Needs

  • Interviews with the client/caregiver
  • Daily observation of activities
  • Consultation with co-workers from different shifts
  • Volunteers (if applicable)
  • Nurses assistants, physiotherapists, psychologists, and other allied health practitioners
  • Kitchen staff, gardeners, administration staff
  • Social and Cultural Profile” (given to client/caregiver to fill in)

Identification of Needs Defined

Staff should address the needs of clients and their families in a holistic way. This means that the assessment focuses on the whole person and their entire well-being, including physical, emotional, spiritual, mental, social and environmental.

The Social & Spiritual Profile collects a client’s personal as well as confidential information that the facility may or may not share in the future and therefore should have secure storage.

Gathering information may require more than one meeting with clients.
Some of the customary ways in which the needs are identified include:

  • Client interview
  • Family/friend interviews
  • Observation data gathering

Tips for conducting a Client Interview

Be supportive and non-judgemental to encourage cooperation.

  • Explain to clients what you are trying to find out and why.
  • Try to find a common interest to talk about or break the ice by observing something in or around where the interview is taking place e.g. pictures on the wall, a piece of furniture, magazines etc.
  • Listen attentively and let clients talk; you may find out things you never thought about asking.
  • Enquire about past hobbies and current preferred entertainment.
  • Gently support your clients to take responsibility for their own problems/needs.
  • Assist clients to set realistic goals (priority goals, long-term or short-term goals?)

Tips for Conducting Family/Friend Interviews

Talking to family and friends may provide useful information about clients. Use discretion and be courteous.

  • Establish current family’s dynamics and lifestyle.
  • Encourage participation in facility’s activity programs (concerts, major events, and bus trips).
  • Seek advice and recommendations regarding relative’s care preferences.
  • Provide information about the range of activities and choices available through the recreation program.
  • Liaise with family when developing care plan.
  • Invite family to attend/join bi-monthly ‘Residents’ & Relatives Meeting’.
  • Invite relatives to participate in ‘Family Council Meetings’ (if applicable), to share concerns.

Related: Communication Strategies that Improve Client Engagement

Tips for Gathering Information through Client Observation

  • Observe client interactions with peers at meal times.
  • Take note of verbal and non-verbal communication.
  • Notice client’s mobility during the day e.g. able to sit down but needs assistance to stand up, unable to go to the toilet alone, able to drink from cup but not able to pour drink.
  • Classify recreation assistance required e.g. supervision, escorting, extra support, wheelchair required.
  • Consult other employees that come into contact with client e.g. domestic staff, gardeners, volunteers, Chaplains, and others

Some Useful Questions to Ask

  • Explore what aspect of their profession they enjoyed.
  • Find out what abilities clients have or lack that affects social/leisure activities? e.g.
    • Physical: mobility, dexterity
    • Sensory: vision/hearing impaired
    • Cognitive; attention span, behaviour, dementia status.
  • Cultural background: would they like access to ethnic radio, special religious service, affiliation with clubs related to their background?
  • Observe client personalities e.g. loners, extroverts, fun loving, melancholic.
  • Seek recommendations from caregivers/clinical health providers regarding clients with specific needs (Alzheimer's Disease, vision deficiency, emotional needs.)
  • What type of activity is more suitable: active or passive?
  • What hobbies/craft/music and other activities would appeal to them?
  • What barriers, real or perceived, could affect social/leisure activities? E.g. unmet emotional needs, family estrangement, painful memories, mobility issues, depression, and other issues.
  • What strengths do clients have? What remaining abilities can be improved upon?
  • How can a client’s spiritual well being be supported?

Next Step: Developing a Care Plan

Before developing a care plan, it is important that staff communicate with other health practitioners to gather information outside the scope of their own roles e.g. behaviour management, psychological issues, and special dietary requirements amongst others.

Related: How to Write a Care Plan

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Comments   Post a Comment

Kayan 21st Jul 2022 Lpn
Explain how trainees are required to handle information that is gathered from clients records.
Susan 22nd Jul 2022 Activity Director
Hi Kayan
Students should never share information about a client
It is confidential
If they need to do a practice assessment for school they should use a fake name
I have never heard of doing an assessment and not using the patient’s name
Kayan 21st Jul 2022 Lpn
Explain why should you avoid using a client's actual name during an assessment?
Temmy Bright 21st Jan 2021
While giving care to one of your clients, what are the main aspects you look for to establish a personal history of your client and what is the approach of care you will provide to meet the clients need.

2. As a care assistant, hoew would you record information and findings and how would you assist these patients ,how woulds you share this information with others e.g superior,colleague, relative and residents herselfs
Mrs Borg suffers from diabetes melitus
Susan 22nd Jan 2021 Activity Director
Hi Temmy
I think this article has some good ideas as to how to establish a personal history
I would assume you are given some information about this person when they were admitted to your care
That information along with talking to the person and their family and friends if they are available you are caring for and observation you should be able to establish what you need to do
Diabetes can be serious condition depending on how bad it is
The doctors and your boss should give you some pointers about this
I assume you have a way of documenting what you have done and your observations
You can always use this tool kit
Susan 5th Sep 2020 Activity Director
I think this article was written in 2015
Jacinta Kelly 5th Sep 2020
Hi, can you give me the year that this was published as I would like to use this page as a reference please. Thank you
Marjorie borje 2nd May 2020
Hi I have a question why do you need to determine and confirm the client level of participation in meeting their personal care needs?

Thank you !
Nikki Merakis 24th Feb 2020
The client’s stage of life, development and strengths must be assessed when engaging in support activities explain why?

i am currently studying a diploma in health and leisure
Susan 25th Feb 2020 Activity Director
The short answer is that you want to provide appropriate activities for the client and this information helps you to do that
Juliet 2nd Feb 2020
How would you consider the care of a client how does not speak the same language as you. Address possible client needs that may be unmet. Determine any considerations for you to take to improve quality of care. I need help to answer this question.
sally 28th Jan 2020
HI I have a Question describe two different appropriate referral source and the protocols that could accompany the referral process
Nikki 31st Dec 2019
I'm stuck someone please help me last question to submit my unit

Organisations use procedures to standardise the processes for coordinating services for older people. What procedures would you expect to find to describe how to liaise with experts? List at least three processes that might have their own procedure.
Susan 1st Jan 2020 Activity Director
Hi Nikki
I am not sure exactly what you’re asking and I am not sure where you are from
In the US each state has organizations that help the elderly
For example there is an elder care organization a council on aging and visiting nurses which can connect elders to other services such as meals on wheels and outpatient therapy
If this is not what you’re looking for can you be a little more specific otherwise I hope this helps
Solange 2nd Jan 2020 Diversional Therapist
Hi, I can think of three: 1 Confidentiality 2 Complaints 3, Residents’ Rights. They all have their own Policies & Procedures. If there is a problem with any of the above expert/professional help is required.
Julie Ann Delgado 12th Nov 2019
Hi there, I hope that you can help me out with my questions about the care plan.

"How would you ensure that the clients preferences are met by the services?" and give examples to support the answer.
Examples of external and internal opportunities for feedback opportunities in your role as a support worker.

Hope to hearing from you.

Mandy ford 20th Jul 2019
Hi there I have a Q which is list 5 sources of information for individual program plan development can anyone please help? Tia Mandy
Thanya 28th Jun 2019
Hello is there anyone here who could help me with this question.
I am just studying provide individualised support. I struggle with fews questions. I can't find the answer.. Can anyone help me? My questions​is
1. How would you gather information about the client, covering theirprivacy and confidentiality?
2. What type of assistance​ can you provide, to help an aged person/ person with disability, with celebration and special events?
3.Explain with examples why you needto monitor the support activities that are being implemented​ as part of a person' individualised​ plan.
Thank you very much!
Sharon 26th Feb 2019 Carer
hi i need some articals on complex needs and disability i have to plan one leisure and health activity for 3 clients with complex needs of which one person with a disability can any one help or sugest a site i can use
Jacob Anou 18th Oct 2018
Where would you find a resident physical support needs profile template?
Caitlin Crawford 26th Jul 2018
What are three important physical capilities might the client be assessed for when developing a care plan??
Solange 28th Jul 2018 Diversional Therapist
Hi, Caitlin -Elders’ physical capabilities:
Dexterity; does the client have good grip strength?
Mobility/Balance: How difficult is walking/turning around? Can he/she get up and go? Do they rely on the staff’s help?
Stamina: What is the dimension of his/her tiredness? Can they stay awake without nodding off during activities?
Talita 18th Jun 2018
There is an article regarding advocacy here:
christine 12th Jun 2018
doing a project an need some ideas
my question is
Explain your process for advocating on behalf of a client and keeping the client informed on progress
julie 8th Aug 2015 Diversional Therapist
Hi, just finished reading article, and is as i do but was good to refresh the old memory box. Thanks
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