What is a Clinical Assessment?

A clinical assessment, sometimes also referred to as a health assessment, is a documented process that is used to evaluate and diagnose individuals’ overall well-being, whether mental, physical, or both. Evaluators tend to use standard rubrics and checklists for quantifying health, wellness, and fitness. In most cases these assessments are similar in format to a routine health check-up or physical, but the driving reasons why each is done tends to be different. While a check-up is typically designed as a periodic measure of health for personal and preventative reasons, a more formal assessment is usually done because it’s required for some purpose. Employers, insurance companies, or even government agencies may insist that people undergo assessment before they can be hired, paid, or promoted, for instance.

In most cases the main goal of any clinical assessment is to get a standardized and quantifiable understanding of a person’s health. These assessments provide results that only take into account the individual that is being evaluated rather than evaluating individuals based on data that is compiled from multiple sources, and as a result they tend to be highly specific and are in many cases often quite detailed. Some are geared towards mental health, while others are looking for overall wellness; still more are looking for more specific measures of cardiovascular strength or fitness level.

A lot depends on who is ordering the test and why it is being done. In nearly all cases, though, the assessments are conducted by trained medical professionals, and the results are usually intended to be streamlined so that individual results can be quickly and meaningfully compared against each other. When evaluators uncover problems they usually recommend that the person impacted get treatment, but it is usually somewhat rare for that specific professional to be the one providing the treatment. Evaluators don’t always take on their own patients, and many work full-time conducting assessments. Most are able to make referrals, though, and can recommend different courses of action.

In most cases assessments follow a somewhat streamlined protocol no matter where they’re conducted or by whom. Everything from the questions to be asked and the measurements to be taken to the ways to fill out paperwork and the proper presentation of findings is usually uniform. What this uniformity looks like can vary from jurisdiction to jurisdiction, and in most cases an oversight committee for a particular city, state, or country is the one to set the standards and decide on the baseline requirements. Within each specific place, though, the results should be more or less equivalent.

It’s not uncommon to find separate protocol for mental and physical assessments, and the two are often performed separately. Internal medicine specialists are more commonly tracked to perform physical tests, too, while mental health experts and psychiatrists tend to fill out forms about emotional health and stability.

Some clinical assessments are mandated by government agencies to ensure safe medical practices, or to disburse related health benefit payments to patients. These are usually intended to make sure that all available medical treatment options are in a patient’s best interest. People may be required to submit to a formal assessment before claiming social welfare payment for something like a disability, and may also have to undergo evaluation before receiving an insurance payout.

In the United States, the Centers for Medicare and Medicaid Services require a clinical assessment that is referred to as a minimum data set (MDS) for all patients admitted to long-term care facilities that are certified to receive Medicare or Medicaid benefits. The initial assessment is required by the 14th day of the resident’s stay, and additional assessments are required quarterly and yearly. In most cases patient results are submitted electronically to the government and kept on file for future use and reference.

Employers sometimes also require these sorts of evaluations, often as a precursor to hiring or, depending on the job, as a condition of promotion or continued employment. In some cases, the employer may consult with a medical professional to develop or analyze wellness assessments and assist in planning or implementing programs to improve results. Although this assessment can be costly for an employer, it often improves profitability over time by decreasing healthcare costs and improving employee productivity.