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

Elicits the patient’s health beliefs, values, preferences, expressed needs, goals, and self-care behaviors, and knowledge of her or his healthcare situation.

Obtains an accurate medication history and identifies medication discrepancies.

Identifies deficits and barriers to effective performance of self-care management skills/behaviors.

Involves the patient, family, other caregivers, and other healthcare providers in holistic data collection.

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

Recognizes the influence of personal attitudes, values, and beliefs, and the need to remove any bias.

Assesses family dynamics, coping and caregiving skills, knowledge, and impact on patient health and wellness.

Prioritizes data collection based on the patient’s immediate condition and the anticipated needs of the patient, family, and other caregivers in the home.

Uses appropriate evidence-based assessment techniques, instruments, and tools, such as falls risk assessments, nutritional assessment, pain scales, depression scales, and cognitive level measures.

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 patient and other data and information.

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

Promotes sharing of assessment data through an electronic health record.

Documents relevant assessment data in a retrievable format.

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

Uses known or innovative evidence-based assessment techniques and tools.

Performs advanced assessments of home health patient populations with specific or complex needs.

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

Derives physical, psychosocial, and culturally appropriate expected outcomes from the diagnoses.

Involves the patient, family, other caregivers, healthcare team members, and others in formulating expected outcomes.

Collaborates with the patient to develop SMART goals (specific, measurable, achievable, relevant, and time-defined).

Integrates the patient’s goals when formulating expected outcomes.

Considers associated risks, benefits, costs, potential barriers, current scientific evidence, and expected trajectory of the condition when formulating expected outcomes.

Defines expected outcomes in terms of the patient’s culture, values, and ethical beliefs.

Includes a time estimate for the attainment of expected outcomes.

Develops expected outcomes that support continuity of care.

Modifies expected outcomes according to changes in the status of the patient, family, other caregivers, or home environment.

Documents expected outcomes as measurable changes in the patient’s status.

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, continuity, and consistency among providers.

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

Serves as a role model to staff investigating the latest evidence to support improvement of outcomes.

Uses technology to incorporate evidence-based interventions and facilitate outcome achievement while engaging patients, families, and caregivers in the process.