Collects comprehensive and holistic data, including, but not limited to, physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments, in a systematic and ongoing process while acknowledging the uniqueness of the person.

Elicits the patient’s values, preferences, expressed needs, and knowledge of the healthcare situation to utilize such information as appropriate within the context of the correctional setting.

Involves the patient, family, correctional staff, and other healthcare providers, as appropriate, in holistic data collection.

Identifies barriers (e.g., psychosocial, literacy, financial, cultural) to effective communication and makes appropriate adaptations.

Recognizes the impact of personal attitudes, values, and beliefs on the patient’s health status.

Assesses the impact of family dynamics on the patient’s health and wellness.

Prioritizes data collection based on the patient’s immediate condition, or the anticipated needs of the patient or situation.

Uses appropriate evidence-based assessment techniques, instruments, and tools.

Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances.

Applies ethical, legal, and privacy guidelines and policies to the collection, maintenance, use, and dissemination of data and information.

Recognizes patients as the authority on their own health by identifying their care preferences.

Documents relevant data in a retrievable format.

Initiates and interprets diagnostic tests and procedures relevant to the patient’s current status.

Assesses the effect of interactions among individuals, family, community, and social systems on health and illness.

Involves the patient, family, healthcare and community providers, correctional personnel, and others in formulating expected outcomes when possible and appropriate.

Derives culturally appropriate expected outcomes from the diagnoses.

Considers associated risks, security issues, benefits, costs, current scientific evidence, expected trajectory of the condition, and clinical expertise when formulating expected outcomes.

Defines expected outcomes in terms of the patient, patient culture, values, ethical considerations, environment, and situation while considering associated risks, security issues, benefits and costs, and current scientific evidence.

Includes a time estimate for attainment of expected outcomes.

Develops expected outcomes that provide direction for continuity of care.

Modifies expected outcomes according to changes in the patient’s status or evaluation of the situation.

Documents expected outcomes as measurable goals.

Identifies expected outcomes that incorporate scientific evidence and are achievable through implementation of evidence-based practices.

Identifies expected outcomes that incorporate cost and clinical effectiveness, patient satisfaction, and continuity and consistency among providers.

Differentiates outcomes that require care process interventions from those that require system-level interventions.

Develops an individualized plan in partnership with the patient, family, and others considering the patient’s characteristics or situation, including but not limited to values, beliefs, spiritual and health practices preferences, choices, developmental level, coping style, culture and environment, safety, and available technology.