Section A: The Starting Point for the Evaluation
Reason for the evaluation, reassessment, and goals for the individual
Dear Colleagues, Dear Healthcare Professionals,
With this newsletter, we are launching a monthly series dedicated to the various sections of the interRAI HCSvizzera manual.
Each month, we will take a closer look at a section of the instrument, following the order of the manual to highlight the most important assessment criteria, correct coding, and the aspects that most frequently raise questions in practice.
Let’s start with Section A: Administrative Data and Reason for the Assessment.
Why is Section A important?
Section A establishes the foundation for the entire assessment. It helps us understand why the assessment is being conducted, the time period to which the collected information refers, and the person’s current situation.
Inaccurate completion can impair the interpretation of the subsequent sections and make it difficult to compare different assessments over time.
The Reason for the Assessment
One of the first steps is to correctly state the reason for conducting the assessment.
This may include, for example:
an initial assessment;
a periodic reassessment;
a reassessment following a significant and permanent change;
a return after an absence or a hospital stay;
an interruption in care;
another reason specified in the form.
The reassessment must be conducted at least every nine months, upon expiration of the mandate, or in the event of a permanent change in the person’s situation.
The form also provides for additional reasons for an assessment, which must be coded according to the specific situation.
%C8 Therefore, it is important not to select the reason automatically, but to verify which option correctly describes the reason for conducting the assessment.
A date that defines the entire assessment
The reference date defines the time period to which the observations must refer.
Many items in the interRAI HC cover the three preceding days, including the reference date, while others specify different time periods. Before coding, it is therefore always necessary to review the observation period specified for each item.
If the assessment is conducted over multiple sessions, the information must still refer to the same time period that was originally specified.
The Goals Formulated by the Individual
Section A contains more than just administrative information. The section on goals allows the individual to express what they hope to achieve through the support.
The goals may relate, for example, to the following:
maintaining independence;
the ability to remain in their own home;
regaining a skill;
greater safety in daily life;
improving relationships and social participation.
The professional must repeat the goal formulated by the person without replacing it with what they believe the goal should be.
If the person is unable to formulate their own goal, “none” should be indicated.
Goals must never be invented by the professional.
The living situation is also part of the assessment
The questions regarding the living situation and household composition help to understand the context in which care takes place.
Living alone, living with a partner, with children, or with other people can influence available resources, the need for support, and the planning of interventions.
This information is therefore not merely personal data, but helps create a truly person-centered picture.
A Common Mistake
A reassessment is initiated because the service agreement is expiring. In the meantime, however, the person’s situation has changed significantly and permanently.
Automatically selecting “regular reassessment” without taking the change into account would not accurately reflect the reason for the assessment.
The coding must be selected in accordance with the actual situation and the information in the manual.
Further Information
This newsletter highlights some key points from Section A but does not replace the official instructions.
To learn about all the reasons for an assessment, the corresponding codes, and examples of use, please consult the interRAI Home Care Switzerland manual.
Would you like to learn more about using interRAI HC Switzerland?
In our Italian-language courses, Esther Chapman guides healthcare professionals through the use of the tool—from correct coding to reading the scales and CAPs, all the way to care planning.
On our website, you’ll find the current calendar and information about the upcoming interRAI HC courses.
An accurate assessment is the first step toward truly individualized care.
Swiss Chapman Consulting SAGL
