SH CP 43

Physical Assessment and Monitoring

Policy
Version: 4

Summary: The purpose of this policy is to provide the minimum

standards of integrated care provision by all clinical
staff of Southern Health NHS Foundation Trust for
physical health assessment, monitoring and
management of identified physical health needs in
both inpatient and community settings.

For guidance on implementing this policy, please refer

to the Physical Assessment and Monitoring Procedure
for Mental Health and Learning Disabilities or the
Physical Assessment and Monitoring Procedure for
Integrated Community Services as appropriate.

Keywords (minimum of 5): Physical; Assessment; Monitoring; Policy; SH CP 44;

Deteriorating, Deteriorating patient, Deterioration; Vital
signs, NEWS 2, PEWS, Non-contact observations

Target Audience: All clinical and healthcare support staff

Next Review Date: August 2019

Approved & Ratified by: Patient Safety Group Date of meeting:

23 August 2018

Date issued: March 2019

Author: Steve Coopey, Simon Johnson, Dr Juanita Pascual

Accountable Executive Lead:
Consultant, Dr Rachel Anderson Consultant, Paula
Hull Interim Director of Operations ISD, Sara
Courtney Acting Director of Nursing
Paula Hull, Director of Nursing and Allied Health
Professionals

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Change Record

Date Author Version Page Reason for Change

18/06/12 Kayode Osanaiye / Amit Malik /
Steve Coopey / Simon Johnson
June 13 1 5 Clarification of exclusion criteria
8 Clarification All patients to have Physiological observations
as part of base line assessment
April Dr Rachel 2 Policy review
2017 Anderson, Dr
Juanita Pascual
May 2017 Paula Hull, Sara 2 Policy review
Courtney
August Briony Cooper 2 Policy review
2017
July 2018 Kerry Lewis 3 Removal of section 4.4 and addition to section 4.3
Amendments to section 5. Addition of section 5.1.8
Addition of appendices.
February Kerry Lewis 4 Addition of reference to Non-Contact observations
2019 throughout document
February Hayley Stockford 4 Addition of reference to Paediatric Early Warning Score tool
2019 throughout document
April Kerry Lewis 4 8 Addition of New Forest Frailty Team NEWS 2 SOP
2019 reference

Reviewers/contributors

Name Position Version Reviewed &

Date

Sarah Garland
Paula Hull Interim Head of Nursing and Quality (ICS)
Shelley Mason
Sandi Igafell Team Manager
Jude Diggins
Abigail Barkham
Trudi Archer
Sarah Baines
Una Hobson Locality Senior Nurse (Learning Disability)
Lesley Stevens Clinical Director, AMH
Fiona Hartfree Divisional Lead Nurse, AMH
Dr Rachel Anderson
Dr Juanita Pascual
Sara Courtney Acting Director of Nursing
Paula Hull Interim Director of Operations ISD
Kerry Lewis Resuscitation Officer Version 3, July 2018
Hayley Stockford Resuscitation Officer Version 3, July 2018

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 Contents

Page

1. Introduction 4
2. Scope 6
3. Definitions 6
4. Duties/ responsibilities 6
5. Process 7
6. Training requirements 9
7. Monitoring compliance 9
8. Policy review 9
9. Associated documents 10
10. Supporting references 10

Appendices
A1a Physiological Observation Chart, Track and Trigger 12
A1b Southern Health all cause deterioration (including sepsis) 14
guidance
A1c Southern Health all cause deterioration (including sepsis)
guidance (for 12-18 year olds in inpatient settings) 17
A1d Non-contact observations 20
A2 SBAR(D) 22
A3 Neurological Observation Chart 25
A4a Physical assessment and monitoring clinical competencies 29
A4b Physiological Observations (Adult Track and Trigger) and SBAR 32
clinical competencies
A4c Blood glucose monitoring clinical competency 34
A4d Pain assessment clinical competencies 36
A4e Physiological Observation Chart (NEWS) 2 and SBAR(d)
competency assessment 38
A4f Physiological Observation Chart (PEWS) and SBAR(d)
competency assessment 40
A4g Competency Rating Scale 42
A5 Training Needs Analysis (TNA) 43
A6 Equality Impact Assessment (EqIA) 44

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 Physical Assessment and Monitoring Policy

1. Introduction

1.1 The purpose of this policy is to provide minimum standards of integrated care provision by
all clinical staff of Southern Health NHS Foundation Trust for physical health assessment,
monitoring and management of identified physical health needs in both inpatient and
community settings. The policy covers the following:

 Initial examination and/or clinical risk assessment of existing and new patient/service
user
 On-going assessment and screening to ensure early identification of physical health
problems
 Timely investigation, monitoring and follow-up of physical health problems, including
appropriate referral to other health services as necessary
 Promotion of positive lifestyle change e.g. healthy eating, smoking cessation, where
indicated
 Informing service users of the nature, purpose and likely side effects of their individual
medications and in particular, the effect on their physical health.
 Standards in relation to sharing clinical information i.e. handover

1.2 The terms ‘patient’ and ‘service user’ are used interchangeably to relate to anyone
accessing physical and/or mental health services, social care and learning disability
services. Whilst this policy outlines the role that Trust clinical staffs have in supporting the
physical health and well-being of service users, it also recognises that this is often provided
in partnership with primary care. In some settings the main role of Trust clinical staff is in
promoting and enabling access to mainstream health promotion, health screening and
physical health services in primary and secondary care. The overarching principles will
apply to all services; the implementation of this policy will be in close co-operation with
primary care, secondary care, Ambulance service and all SHFT services in line with
established practice as per the procedures defined within this policy.

1.3 This policy is intended to manage the following:

 Promote awareness of the importance of physical health monitoring.

 Identify service users that may have a pre-existing physical health problem or medical
condition.
 Monitor service users’ physical health problems which may change while under our
care.
 Identify deterioration or improvement to physical health of service users through
effective communication and handover.
 Improve service users awareness and adequate knowledge of the potential side effects
of their medications and lifestyle behaviours which may affect their physical and mental
health.
 Lack of awareness of previous use of alcohol, nicotine and other substances could
adversely affect management of both physical and mental wellbeing.
 Raise awareness of accessing health promotion/ screening/ primary and secondary
physical health care.
 Introduce a standardised physical assessment appropriate to the needs of the service
user.
 Offer education and training to ALL clinical staff in order to develop clinical decision
making skills in physical health assessment monitoring.
 Acknowledge that a service user may be too disturbed or may refuse physical
examination or assessment and to ensure this is followed up and documented
appropriately.

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1.4 A holistic approach is essential to all aspects of good physical and mental health care and
this includes the active identification and management of physical health needs. People
with an existing physical and/or mental illness are prone to physical illness than the general
population, may not receive the optimum physical healthcare that they need and have an
associated higher morbidity and mortality than the general population. Physical illness can
have a significant impact on a person’s mental health and conversely mental illness can
seriously impact on a person’s physical health. Prescribed medications are associated with
important and sometimes serious physical side effects which can result in increased risk of
disease e.g. cardiovascular disease. Patients with poor physical health and/or mental
illness may be prone to the effects of poverty and poor quality life-style.

1.5 People with Learning Disabilities have a lower life expectancy compared to the general
population. They have a high prevalence of general health problems, noted within the public
health strategy for England (DH, 2010) which stated that people with learning disabilities
have significantly poorer life expectancy than would be expected based on their
socioeconomic status alone. Health problems include Cancer, Coronary Heart Disease,
Respiratory Disease, Epilepsy, Dementia, Mental Illness, Osteoporosis, Poor Oral Health,
Hypertension, Thyroid disorder, Diabetes: Michaels J (2008); The Confidential Inquiry team
(2011), St. Georges: University of London (2012).

1.6 It is the responsibility of all Southern Health NHS Foundation Trust staff to be actively
involved in health promotion which should include open discussion and use of appropriate
literature.

1.7 Areas to be considered should include exercise, smoking cessation, information about
alcohol and safe drinking, physical effects of substance misuse, dietary advice and sexual
health. In in-patient settings, the ward manager will ensure healthy choices and
opportunities to be physically active are available to service users.

1.8 Some service users/ patients can be reluctant to visit their GP and are generally less likely
to report physical problems or access preventive health services. It is therefore essential
that the physical health of both in-patients and community patients should be actively
monitored and any identified health needs managed. For community patients,
arrangements for physical monitoring and treatment should where possible be made in
partnership with the patient’s GP. However, clinical decisions around frequency of
observations can be made by Nurse in charge.

1.9 Physical observations may not be appropriate in certain circumstances where alternative
forms of documentation are already in place. Exclusions may include:

I) End of Life Care

ii) Patients in Minor Injuries Unit
iii) Patient undergoing an invasive procedure e.g. theatre / ECT / endoscopy

1.10 The NHS continues to face the challenge of responding to patients’ needs and expectations
by encouraging and supporting new ways of working, and this includes patient choice. One
of the biggest changes is to challenge traditional roles and views of how to deliver care by
appropriately skilled practitioners.

1.11 Our patients are very much at the centre of this change, and the recognition of those whose
health condition is deteriorating or is at risk of doing so is key to avoiding unnecessary
hospital admissions and keeping care closer to home. Critical care without walls (outside
specialist units) (DH, 2000b) ensures that appropriately trained, highly skilled, safe
practitioners deliver the best possible care in the community

1.12 The handover of crucial clinical service user information is vital to ensuring appropriate
monitoring of a service user during all aspects of care in particular during transfers of care.

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 A systematic evidence based handover tool that is appropriate to the service user area
should be used e.g. SBAR (d).

2. Scope

2.1 This policy does not cover every aspect of good physical health care or detail monitoring
requirements relating to specific drugs and so must not replace a comprehensive clinical
assessment and judgment.

2.2 All clinical staffs are required to carry out on-going monitoring of the health and wellbeing of
service users and to support service users to access their GP and other relevant health
services as required.

3. Definitions

3.1 Health - The World Health Organization (WHO, 1946) defined Health in its broader sense
as “a state of complete physical, mental and social well being and not merely the absence
of disease or infirmity”. The main determinants of health include the social and economic
environment, the physical environment and the person’s individual characteristics of
behaviours.

3.2 Physical Health is the overall condition of a living organism at a given time, the soundness
of the body, freedom from disease or abnormality and the condition of optimal well being
(Ron Kurtus, 2012) Good physical health in an individual is a state of well being that would
enable an individual to perform their daily routine activities without any hindrance (Daily
Health News).

3.3 Integrated Care is a term that reflects a concern to improve patient experience and
achieve greater efficiency and value from health delivery systems. The aim is to address
fragmentation in patient services and enable a better coordinated and more continuous
care, frequently for an ageing population which has increasing incidence of chronic disease
(What is Integrated Care? Sara Shaw et al; 2011).

4. Duties / Responsibilities

4.1 The Patient Safety Group

Southern Health Foundation Trust has a responsibility to provide an effective and

appropriate service to their service users and appropriate training to their staff. The Patient
Safety Group will monitor compliance of this Policy.

4.2 Clinical leads / Managers / Supervisors

 Will ensure that sufficient priority is given to the successful implementation of the policy
both in in-patient wards and the community.
 Will ensure that all staff attend appropriate training
 Monitor compliance with current standards by all clinical staff
 Ensure the availability, functioning and maintenance of all appropriate materials plus
equipment and that staff have appropriate training to use them.
 Ensure clinical documentation is completed in line with SHFT policy
 Ensure that any change in practice recommendations are notified to all clinical staff
 Review audit results relating to the policy and feedback to staff on deficits identified
 Ensure all staff participate in audit process and any action plans developed to address
deficits
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4.3 Clinicians / Staff responsibilities

 Registered staff will be accountable as per their Professional Body.

 Maintaining clinical competency as per competency framework (SHFT 2011)
 Attending relevant training provided by the Trust and put it into practice
 Bringing to the attention of appropriate senior staff any deficiencies in knowledge,
ability or resources that may mediate against safe clinical practice.
 Participate in audit programmes related to measuring the quality and safety of physical
assessment and monitoring. This would include addressing any improvements required
and celebration of good practice.
 Ensuring they are familiar with relevant policies and procedures in their area of
practice.
 It is the responsibility of individual staff to make sure that the equipment they use is in
correct working order and within servicing dates. For further information refer to SH CP
40 Medical Devices Management Policy.

5. Process

5.1 All patients must have an appropriate holistic assessment of their physical and mental
health needs. This assessment must be appropriately documented as per record keeping
guidance (SHFT). Physiological observations are required for all patients as part of their
base line assessment. For adults in hospitals, the NEWS 2 (National Early Warning Score
2) should be used for initial assessment on admission and for continuous monitoring of
physical observations throughout their stay in hospital (Royal College of Physicians (RCP),
2017). See appendix 1b. In hospitals where NEWS 2 is not yet implemented, Track and
Trigger must continue to be used to record and escalate physical observations, see
appendix 1a. For inpatient child and adolescents, the Paediatric Early Warning Score
(PEWS) should be used (Appendix 1c). Additional content and the procedure for this will
vary depending on the person’s mental or physical illness, medication, age, initial findings
and the involvement of primary care. Issues of sensitivity, gender, ethnicity and preference
should also be considered. See separate Physical Assessment and Monitoring Procedure
for Integrated Community Services and Physical Assessment and Monitoring Procedure for
Mental Health and Learning Disability.

5.1.2 Relevant patient documentation will be obtained from the referring service (for example GP
or Hospital clinician) including current problems, past medical history and medication
history.

5.1.3 The on-going accountability and responsibility for service user physical assessment is with
the relevant health care professional e.g. GP, Consultant, Registered Nurse, Allied Health
Professional (AHP).

All patients must have a clear written monitoring plan in their health record that specifies
which physiological observations should be recorded, and how often. In addition, it should
specify the management of the patient and when they will be reviewed by nursing and
responsible medical staff.

5.1.4 Registered Professionals or delegated staff undertaking physical health assessment and
monitoring must be competent to do so, see section 6 – Training requirements All staff are
accountable for their actions and omissions.

5.1.5 Informed verbal consent must be obtained from the patient to undertake observations.
When a patient refuses, give clear explanations of the importance of observations and why
they are necessary. Always document if a patient refuses consent and refer to the Mental
Capacity Act Policy.
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5.1.6 Physical observations may not be appropriate in certain circumstances where alternative
forms of documentation are already in place:
a) End of Life care
b) Patients in Minor Injury Units
c) Patients undergoing an invasive procedure eg surgery/ECT/Endoscopy

5.1.7 NEWS 2
When the NEWS 2 tool is in use, all patients should have their oxygens saturations
recorded on SpO2 Scale 1 unless they have confirmed hypercapnic respiratory failure on
blood gas analysis on either a prior or their current hospital admission in which case scale 2
can be used (RCP, 2017). This decision must be made by a suitably qualified clinician who
is able to interpret blood gas analysis. For the avoidance of doubt, the clinician making this
decision about which oxygen scale is used should cross through the scale which is not in
use, sign next to this amendment and ensure the medical notes clearly reflect the decision
made.

The New Forest Frailty support team are trialling NEWS 2 prior to the Community team
rollout. There is a local SOP in place for this.

5.1.8 Non-Contact Physical Health Observations

There may be circumstances when taking a full set of physical observations is not possible
or considered to pose significant risk to the service user and/or staff, for example:

 It is not safe to approach the service user

 Approaching the service user may cause significant distress or antagonise the situation
 The service user declines physical observations (the rationale for taking physical
observations must be explained to the service user if appropriate)

In the above circumstances where it is not possible to utilise Track and Trigger/NEWS 2/
PEWS, the Non- Contact Physical Heath Observations Guidance and Assessment
Framework (Appendix 1D)should be used to assess the service user. This framework
provides guidance for staff to assess the service user safely using ABCDE and highlights
important escalation processes to guide interventions moving forward. The use of this
framework is a Registered Nurse decision on a case by case basis.

5.2 Escalation Protocol and graded response

5.2.1 All patients will be monitored using the appropriate physiological Track and Trigger/NEWS
2/PEWS tool (appendix 1a, 1b and 1c). These systems will identify the appropriate graded
response to abnormal physiological observations recorded or guide clinicians who are
concerned.

5.2.2 By using the appropriate escalation protocol (appendix 1a, 1b and1c) as a framework, this
will make sure that patients who are acutely ill or at risk of physical deterioration receive
prompt care and decisions are made in a timely manner.

5.2.3 The healthcare professional recording the vital signs and triggering an escalation response
must document their actions and the management plan in the patients records and escalate
to more senior healthcare professional.

5.2.4 The handover of crucial clinical service user information is vital to ensuring appropriate
monitoring of a service user during all aspects of care in particular during transfers of care.
A systematic evidence based handover tool that is appropriate to the service user area
should be used e.g. SBAR(d) (see Appendix 2).

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6. Training Requirements

6.1 Introduction to the Physiological Observation Chart l is included in Basic Life Support and
Immediate Life Support training. Physical assessment and monitoring training is available
through LEaD e-video learning. Competence in practice should be demonstrated by
completing physical assessment and monitoring clinical competencies, blood glucose
monitoring and pain assessment competency (see Appendix 4a)

6.2 All clinical and healthcare support staff that are taking and recording physical observations
on the Track and Trigger/NEWS 2/PEWS tools should have completed training in physical
health assessment and the associated competencies for the completion and recording of
physical observations (Appendix 4a, , 4b, 4c, 4d, 4e and 4f)) It is the responsibility of the
individual staff member and their Line Manager to ensure they are competent and confident
in obtaining, recording and escalating physical observations.

6.3 All clinical and healthcare support staff taking and recording physical observations at
Community Hospitals where the National Early Warning Score 2 is used should complete
the e-learning training accessed through https://tfinews.helmlms.com/login

Competence in practice must be demonstrated through completion of the Physiological

Observation Chart (NEWS 2) and SBAR(d) Competency Assessment (Appendix 4e). In
addition, prior to the use of NEWS 2, all staff utilising this tool should complete the online e-
learning package, print or save a certificate and complete the Physical assessment
competencies in appendix 4. The e-verifications for these tasks are on the LEaD website
and must be undertaken to record the completion of training. This is in line with the RCP
guidance which recommends that it is mandatory for all staff members utilising the tool to
complete training as per local Trust policy (RCP, 2017).

6.4 For staff working in the child and adolescent inpatient areas, competence in practice must
be demonstrated through completion of the Physiological Observation Chart (PEWS) and
SBAR(d) Competency Assessment (Appendix 4f). The e-verification for this task is on the
LEaD website and must be undertaken to record the completion of training.

6.5 All line managers have a responsibility to ensure staff receive appropriate training and
additional training where relevant to their role, level of responsibility and area of work.

7. Monitoring Compliance

7.1 Compliance with this policy will be monitored as part of the annual clinical audit
programme/Quality Assessment Tool programme. Where deficits are identified through the
audit process or serious incidents, action plans will be developed to ensure these are
addressed and learning is shared.

7.2 In addition, spot checks on a random sample of entries on RiO electronic patient clinical
records or clinical notes will take place where issues have been identified.

8. Policy Review

8.1 To be carried out every three years.

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9. Associated Documents

a. Medicines Control, Administration and Prescribing Policy SH CP 01

b. Medical Emergencies and Resuscitation Policy SH CP 30
c. Risk Assessment and Management of Patients/Service Users Policy
d. Managing Clinical Risk Practice Guidance SH CP 28
e. Policy for Managing Incidents and Serious Incidents SH NCP 16
f. Mental Capacity Act Policy and Guidance
g. Smokefree Trust Policy SH HR 37
h. Physical Observation Chart (Adult Track and Trigger)
i. Neurological Observation Chart
j. Rapid Tranquilisation Policy and Guidance SH CP 48
k. Medicines Reconciliation Policy SH CP 125
l. Physical Assessment and Monitoring Procedure for Mental Health and Learning
Disability Services SH CP 45
m. Physical Assessment and Monitoring Procedure for Integrated Community Services SH
CP 44
n. Infection Prevention and Control Policy SH CP 10
o. Decontamination of Medical Devices Procedure SH CP 100
p. Clinical Record Keeping Policy SH CP 221
q. Do Not Attempt Cardio Pulmonary Resuscitation Policy SH CP 31
r. Blood Glucose Monitoring Protocol SH CP 158
s. Care Planning
t. Medical Device Management Policy SHCP40

10. Supporting References

a. Dept of Health (2006) Choosing Health: Supporting the physical health needs of people
with severe mental illness. DH, London, August 2006.
b. An Acute Problem, National Safety Agency, 2005
c. Dept of Health (1999), National Service Framework for Mental Health. DH, London.
d. A Systematic Approach to the acutely ill patient (Adapted from the Alert course),
resuscitation Council (UK) June 2005
e. Brown S, Inskip H and Barraclough B (2000), Causes of the excess mortality of
schizophrenia, British Journal of Psychiatry, 177, pp 212.
f. The Code Standards of Conduct, Performance and Ethics for Nurses and Midwives,
Nursing and Midwifery Council, April 2008.
g. Cohen A and Phelan M (2001), The Physical Health of patients with mental illness: a
neglected area, Mental Health Promotion Update 2, pp 15-16
h. European Resuscitation Council Guidelines & consensus of science, 2005
i. Phelan M, Stradins L and Morrison S (2001), Physical Health of people with severe
mental illness, British Medical Journal, 322, pp443-4
j. Resuscitation Guidelines 2005 for use in the United Kingdom resuscitation Council
(UK),November 2005
k. NICE (2003) Schizophrenia: Full national clinical guidelines on core interventions in
primary and secondary care, NICE, London (www.nice.org.uk)
l. CPR Guidance for Clinical Practice and Training, Resuscitation Council (UK) 2004,
(2008 updated)
m. Michaels J. (2008): Health Care for All: Report of the Independent Inquiry into Access
to healthcare for People with Learning Disabilities.
n. NICE (2003) Schizophrenia: Full national clinical guidelines on core interventions in
primary and secondary care, NICE, London (www.nice.org.uk)
o. Advanced Life Support Provider Manual 5th Edition, 2005
p. Phelan M & Blair G (2008), Medical history-taking in psychiatry, Advances in
Psychiatric Treatment, 14, pp229-234
q. Health Service Circular 2000.028 Resuscitation Policy
r. Human Rights Act 1998
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 s. Acutely ill patients in Hospital. Recognition of and response to acute illness in adults in
hospital. NICE clinical guidance 50 July 2007
t. Policy for the use of the Modified Early Warning Score (MEWS), Royal Bournemouth
and Christchurch Hospitals NHS Foundation Trust, Jan 2008
u. Using an early warning score tool in community nursing. Nursing Times, May 2008.
v. The Confidential Inquiry team (2011): Improving Health & Lives: Confidential Inquiry.
Short Interim Report: February 2011. The Confidential Inquiry Team. Norah Fry
Research Centre, University of Bristol, 3 Priory Road, Clifton, Bristol. BS8 1TX
w. St Georges, University of London 2012; Understanding Intellectual Disability:
http://www.intellectualdisability.info/mental-health/research-evidence-on -the-health-of-
people-with-learning-intellectual-disabilities
x. Royal College of Physicians National Warning Score (NEWS) standardising the
assessment of acute-illness severity in the NHS
y. Royal College of Physicians (RCP, 2017) National Early Warning Score (NEWS) 2
Standardising the assessment of acute-illness severity in the NHS

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Appendix 1a – Physiological Observation Chart, Track and Trigger

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Appendix 1b Southern Health all cause deterioration (including sepsis) guidance. Adapted from
Royal College of Physicians NEWS 2 tool, December 2017

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Appendix 1c – Southern Health all cause deterioration (including sepsis) guidance
(for 12 – 18 year olds in Inpatient settings)

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 Appendix 1d Non-Contact Observations

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 Appendix 2 – SBARD Tool

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Guidance for using SBAR (d) in Clinical Handovers
Inadequate verbal or written communication is recognised as being the most common root
cause of serious error - both clinically and organisationally. There are some fundamental
barriers to communication across different disciplines and levels of staff. These include
hierarchy, gender, ethnic background and differences in communication styles between
disciplines and individuals.

SBAR(d) is an easy to remember mechanism that can be used to frame communications or

conversations. It is a structured way of communicating information that requires a response
from the receiver. SBAR(d) can be used very effectively to escalate a clinical problem that
requires immediate attention, or to facilitate efficient handover of patients between clinicians
and clinical teams.

SBAR stands for:

S = Situation
B = Background
A = Assessment
R = Recommendation
D = Decision

 These are the key building blocks for communicating critical information that requires
attention and action, thus contributing to effective escalation and increased patient safety.
 Using it helps to prevent breakdowns in verbal and written communication, by creating a
shared mental model around all patient handoffs and situations requiring escalation, or
critical exchange of information (handovers).
 SBAR(d) is an effective mechanism to level the traditional hierarchy between physicians
and other care givers by building a common language platform for communicating critical
events, thereby reducing barriers to communication between healthcare professionals.
Developed by the US Navy, SBAR(d) can be used in the majority of situations and is very
transferable to all communication interactions between professionals.

1. When to use SBAR(d)

SBAR(d) allows staff to communicate assertively and effectively, reducing the vagueness
and the need for repetition. The SBAR(d) process consists of four standardised stages or
prompts that help staff to anticipate the information needed by colleagues and formulate
important communications with the right level of detail. The tool can also be used to
construct letters, emails or other communication at any stage of the patient’s journey.

 Inpatient or outpatient
 Urgent or non-urgent communications
 Conversations with a physician, either in person or over the phone • Particularly useful in
nurse to doctor communications
 Also helpful in doctor to doctor consultation
 Discussions with allied health professionals- e.g. Respiratory therapy, physiotherapy
 Conversations with peers- e.g. change of shift report
 Escalating a concern
 Handover from an ambulance crew to hospital staff
 Verbal or written exchanges
 Emails
 Clinical or managerial environments

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2. What should an SBAR(d) communication convey?

S: Situation
 Identify yourself the site/unit you are calling from
 Identify the patient by name and the reason for your report
 Describe your specific concern

B: Background
 Give the patient's reason for admission (or presentation/referral in community care
settings)
 Explain significant medical history
 Overview of the patient's background: admitting diagnosis, date of admission, prior
procedures, current medications, allergies, pertinent laboratory results and other
relevant diagnostic results.
 Status: Voluntary, Informal, lacks capacity or detained under Mental Health Act
 Current medications and allergies

For this, you need to have collected information from the patient's medical notes

A: Assessment
 Vital signs/physical observations
 Clinical impressions, concerns
 What interventions have you tried already
 What significant risks have been identified?
Risk to self
Risk to others
Self-neglect

R: Recommendation
 Explain what you need - be specific about request and time frame
 Make suggestions
 Clarify expectations
 Finally, what is your recommendation? That is, what would you like to happen by the end
of the conversation with the clinician?
 Any order that is given on the phone needs to be repeated back to ensure accuracy.

D: Decision
 What decision has been agreed?

Read back: Making sure you have been understood.

Following any communication using SBAR, it is important that the receiver of the information
‘reads back’ a summary of the information to ensure accuracy and clarity.
SBAR communications should also be documented in the patients’ medical notes.

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Appendix 3 – Neurological Observations chart

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Appendix 4a: Physical assessment and monitoring clinical competencies

Competency Statement:
The participant demonstrates clinical knowledge and skill in undertaking physical observations
without assistance and/or direct supervision (level 3 - see level descriptors). Assessment in
practice must be by a Registered Health Care Professional who can demonstrate competence at
level 4 or above.

Assessor/self
Performance Criteria Assessment Method Level achieved Date
assessed

The Participant will be able to:

1. Demonstrate the ability to

perform baseline
observations
a) Demonstrate the ability to
measure blood pressure, Questioning and observation
including:

i) recognition of normal blood

pressure range
ii) use of stethoscope
iii) use of manual
sphygmomanometer
iv) use of automated
sphygmomanometer
v) correct choice of cuff
vi) Documentation
vii) Equipment cleaning
b) Demonstrate the ability to
measure radial pulse: Observation
i) rate
ii) rhythm
iii)amplitude
c) Demonstrate the ability to
measure temperature, including: Questioning and observation

i) Recognition of normal
temperature range
ii) Identify factors that may cause
changes in temperature
iii) Identify sites for temperature
measurement
iv) Demonstrate use of single use
strips
v) Demonstrate use of tympanic
membrane thermometer
vi) Demonstrate use of digital
analogue probe thermometer
d) Demonstrate the ability to
measure respirations Observation
i) rate
ii) depth
ii) pattern

e) Demonstrate the ability to Observation

practice in accordance with IP&C
policy, including hand hygiene,
standard precautions and sharps
when undertaking physical
assessment

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 Assessor/self
Performance Criteria Assessment Method Level achieved Date
assessed

2. Demonstrate the ability to

perform pulse oximetry

a) Recognise the indications for Questioning

use of pulse oximetry

b) Identify potential sources of Questioning

error

c) Preparation of patient and Observation

equipment

d) Selection of suitable area for Observation

the probe

e) Take reading of oxygen Observation

saturation and record in patient
notes. Report abnormal readings
f) Clean and store equipment Observation

3. Demonstrate the ability to

perform neurological
observations

a) Identify rational for use of Questioning

neurological assessment

b) Assess patient using Glasgow Observation

Coma Scale

c) Limb movement Observation

d) Pupil reaction Observation

c) Document results and report Observation

abnormal findings

4. Demonstrate the ability to

measure apex / radial pulse

a) Identify rationale for measuring Questioning

apical heart beat

b) Demonstrate procedure for Observation

measuring apical and radial pulse

c) Document results and report Observation

abnormal findings

5. Demonstrate the ability to

collect and analyse urine
samples
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 Assessor/self
Performance Criteria Assessment Method Level achieved Date
assessed
a) Mid-stream collection and Observation
urinalysis test e.g. urine dipstick
test
b) Catheter specimen collection Observation
and urinalysis test e.g. urine
dipstick test

Date all elements of Competency Tool completed to level ________

Name _________________________ Signature _____________________Status___________ Date_______

I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency
in physical observations.

Assessor____________________ Signature __________________ Status ___________ Date _______

Review Competent Health Care Verifier signature Comments

Dates: Yes / No Professional /
Assessor Signature

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Appendix 4b: Physiological Observations (Adult Track and Trigger Tool) and SBAR Clinical
competencies

Competency Statement:
The participant demonstrates clinical knowledge and skill in the use of the Physiological
Observation Chart (Adult track and trigger observation tool and SBAR(d) without assistance and/or
direct supervision (level 3 - see level descriptors). Assessment in practice must be by a Registered
Health Care Professional who can demonstrate competence at level 4 or above.

Assessor/self
Performance Criteria Assessment Method Level achieved Date
assessed

The Participant will be able to:

1. Demonstrate clinical
knowledge and skill in
the use of the
Physiological
Observations Chart
Adult Track and Trigger
Observation Chart
a) Demonstrate knowledge of what Questioning/ Direct observation
baseline observations should be
carried out for all patients
b) Demonstrate knowledge of Questioning/ Direct observation
when the Physiological
Observations Chart track and
Trigger Observation Chart should
be used and when inappropriate
c) Demonstrate ability to perform Direct observation
patient observations including
AVPU
d) Correctly categorise patients Direct observation
using the Physiological
Observation Chart (Adult track and
trigger observation tool)
e) Correctly identify immediate Questioning/ Direct observation
actions required relative to the
Track and Trigger status
f) Use the management algorithm Questioning/ Direct observation
relative to the clinical area

g) Correctly identify transfer Questioning/ Direct observation

urgency category (if applicable)

h) Construct an appropriate Questioning/ Direct observation

management plan resultant from
identified clinical needs. Ensure
frequency of observations are
documented and updated.
2. Demonstrate clinical
knowledge and skill in the
use of SBAR(d)
a) Demonstrate knowledge of Questioning
when SBAR(d) can be used

b) Demonstrate knowledge of the Questioning/ Direct observation

four stages and what information
should be communicated in each
stage

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 Assessor/self
Performance Criteria Assessment Method Level achieved Date
assessed
c) Demonstrate accurate recording Questioning/ Direct observation
of SBAR(d) in patients notes

Date all elements of Competency Tool completed to level ________

Name _________________________ Signature _____________________Status___________ Date_______

I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency
in the use of Physiological Observation Chart (Adult track and trigger observation tool and SBAR(d)

Assessor____________________ Signature __________________ Status ___________ Date _______

Review Competent Health Care Verifier signature Comments

Dates: Yes / No Professional /
Assessor Signature

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Appendix 4c: Blood glucose monitoring clinical competency

Competency Statement
The participant demonstrates clinical knowledge and skill in blood glucose monitoring without
assistance and/or direct supervision (level 3 - see level descriptors). Assessment in practice must
be by a Registered Health Care Professional who can demonstrate competence at level 4 or
above.

Assessor/self
Assessment Method Level achieved Date
Performance Criteria assessed

The Participant will be able to:

1. Demonstrate the
knowledge and skills to
perform blood glucose
monitoring
a) The reason for the patient Questioning
needing blood glucose monitoring

b) The limitations of using a blood Questioning

glucose meter

c) The rationale for calibrating Questioning

meter, ensuring test strips are in
date, performing internal Quality
Control (QC) and external quality
assurance (QA)
d) Correct method to obtain blood Questioning
sample

e) Significance of test results and Questioning

how to interpret

f) When it is necessary to Questioning

refer to a GP or the diabetes nurse
specialist

2. Demonstrate practical skill

in blood glucose
monitoring
a) How to ensure accuracy of Observation
meter and quality control

b) Correct calibration procedure if Observation

needed for meter

c) How to operate the meter Observation

d) Correct procedure for skin Observation

preparation

e) Correct method to obtain blood Observation

sample

f) Practices in accordance with Observation

Trust Infection Control Policy and
Sharps Safety and Management
policy to avoid needle stick injury
g) Practices in accordance with Observation
Trust Infection Control policy,
Hand Hygiene Policy and
Standard Precautions to avoid
contamination and cross infection.

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 Assessor/self
Performance Criteria Assessment Method Level achieved Date
assessed
h) Demonstrates correct Observation
decontamination of equipment
according to IP&C policy
i) Interprets and actions results in Observation
accordance with role and
responsibilities
j) Documents all care given in Observation
accordance with Trust policy &
procedures
Source: SHFT Blood Glucose Monitoring Protocol SH CP 158 2015

Date all elements of Competency Tool completed to level ________

Name _________________________ Signature _____________________Status___________ Date_______

I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency
in blood glucose monitoring

Assessor____________________ Signature __________________ Status ___________ Date _______

Review Competent Health Care Verifier signature Comments

Dates: Yes / No Professional /
Assessor Signature

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Appendix 4d: Pain assessment clinical competencies

Competency Statement:
The participant demonstrates clinical knowledge and skill in pain assessment without assistance
and/or direct supervision (level 3 - see level descriptors). Assessment in practice must be by a
Registered Health Care Professional who can demonstrate competence at level 4 or above.

Assessor/self
Assessment Method Level achieved Date
Performance Criteria assessed

The Participant will be able to:

1. Demonstrate the ability to

recognise and assess pain
a) Recognise the possibility of pain Questioning
in people and be aware of
their reluctance to acknowledge or
report pain

b) Enquire about pain (using a Questioning / observation

range of descriptors e.g. sore,
hurting, aching) when completing
a patient health assessment
c) Assess the pain from a Questioning / observation
multidimensional perspective
including:
i) sensory dimension – nature,
location and intensity of pain
ii) affective dimension – emotional
component and response to pain
iii) impact – on functioning at the
level of activities and participation
d) Identify the location of the pain Questioning / observation
by:
i) asking the patient to point to the
area themselves
ii) use pain maps to define location
and extent
e) Use a standardised intensity Questioning / observation
rating scale, preferably a simple
verbal rating scale or numeric
rating scale if the patient is able to
use these
f) Make every effort to facilitate Questioning / observation
communication particularly with
those people who are sensory
impaired.

Use appropriate self-reporting

assessment scales to suit the
strength of the individual
g) Offer people with moderate to Questioning / observation
severe communication problems
additional assistance.

Use an observational assessment

of pain behaviour In people with
severe impairment, and in
situations which may cause pain

Include insights from family or

carers to interpret the meaning of
their behaviours

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 Assessor/self
Performance Criteria Assessment Method Level achieved Date
assessed
h) Include a careful physical Questioning / observation
examination to identify any
treatable causes
i) Re-evaluate pain using the same Questioning / observation
pain assessment tool to evaluate
the effects of treatment
Source: The assessment of pain in older people: national guidelines 2007 RCGP, BGS and BPS

Date all elements of Competency Tool completed to level ________

Name _________________________ Signature _____________________Status___________ Date_______

I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency
in the assessment of pain.

Assessor____________________ Signature __________________ Status ___________ Date _______

Review Competent Health Care Verifier signature Comments

Dates: Yes / No Professional /
Assessor Signature

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Appendix 4e: Physiological Observation Chart National Early Warning Score (NEWS) 2 and
SBAR (D) Competency Assessment

Name: Role:

Base: Date initial training completed:

Competency Statement:

The participant demonstrates clinical knowledge and skill in the use of the Physiological Observation Chart (NEWS2 tool and
SBAR(d) without assistance and/or direct supervision (level 3 - see level descriptors). Assessment in practice must be by a
Registered Health Care Professional who can demonstrate competence at level 4 or above.

Assessor/self
Performance Criteria Assessment Method Level achieved Date
assessed

The Participant will be able to:

1. Demonstrate clinical knowledge
and skill in the use of the
Physiological Observation
Chart NEWS 2 Tool
a) Demonstrate knowledge of what Questioning/ Direct observation
baseline observations should be
carried out for all patients
b) Demonstrate knowledge of when Questioning/ Direct observation
the Physiological Observation Chart
(NEWS 2 Tool) should be used and
when inappropriate
c) Demonstrate ability to perform Direct observation
patient observations including ACVPU

d) Correctly score patients Direct observation

using the generic assessment /
scoring document (see NEWS 2
scenarios)
e) Correctly identify immediate Questioning/ Direct observation
actions required relative to the NEWS
2 status
f) Use the management algorithm Questioning/ Direct observation
relative to the clinical area

g) Correctly identify transfer urgency Questioning/ Direct observation

category (if applicable)

h) Construct an appropriate Questioning/ Direct observation

management plan resultant from
identified clinical needs

2. Demonstrate clinical knowledge

and skill in the use of SBAR(d)

a) Demonstrate knowledge of when Questioning

SBAR(d) can be used

b) Demonstrate knowledge of the four Questioning/ Direct observation

stages and what information should
be communicated in each stage
c) Demonstrate accurate recording of Questioning/ Direct observation
SBAR(d) in patients notes

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Date all elements of Competency Tool completed to level 3________

Name _________________________ Signature _____________________Status___________ Date_______

I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency in the use
of the NEWS 2 and SBAR

Assessor____________________ Signature __________________ Status ___________ Date _______

I can confirm that the above named individual has completed the NEWS 2 e-learning via MLE and has retained evidence of
completion.
Date NEWS 2 e-learning completed ________________

Assessor ___________________ Signature___________________ Status ______________ Date ________

Review Competent Health Care Verifier signature Comments

Dates: Yes / No Professional /
Assessor Signature

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 Appendix 4f

Physiological Observation Chart PEWS and SBAR (D) Competency Assessment

Name: Role:

Base: Date initial training completed:

Competency Statement:

The participant demonstrates clinical knowledge and skill in the use of the Physiological Observation Chart PEWS
tool and SBAR(d) without assistance and/or direct supervision (level 3 - see level descriptors). Assessment in
practice must be by a Registered Health Care Professional who can demonstrate competence at level 4 or above.

Level Assessor/self
Performance Criteria Assessment Method Date
achieved assessed

The Participant will be able to:

1. Demonstrate clinical knowledge and skill in

the use of the Physiological Observation
Chart PEWS Tool
a) Demonstrate knowledge of what Questioning/ Direct
baseline observations should be observation
carried out for all patients
b) Demonstrate knowledge of when Questioning/ Direct
the Physiological Observation Chart observation
PEWS should be used and
when inappropriate
c) Demonstrate ability to perform Direct observation
patient observations including ACVPU

d) Correctly score patients Direct observation

using the assessment /
scoring document (see PEWS scenarios)
e) Correctly identify immediate Questioning/ Direct
actions required relative to the PEWS score observation

f) Use the management algorithm Questioning/ Direct

relative to the clinical area observation

g) Correctly identify transfer urgency Questioning/ Direct

category (if applicable) observation

h) Construct an appropriate Questioning/ Direct

management plan resultant from observation
identified clinical needs

2. Demonstrate clinical knowledge and skill in

the use of SBAR(d)

a) Demonstrate knowledge of when Questioning

SBAR(d) can be used

b) Demonstrate knowledge of the four Questioning/ Direct

stages and what information should observation
be communicated in each stage
c) Demonstrate accurate recording of Questioning/ Direct
SBAR(d) in patients notes observation

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Date all elements of Competency Tool completed to level 3

Name _________________________ Signature _____________________Status___________ Date_______

I confirm that I have assessed the above named individual and can verify that he/she demonstrates competency
in the use of the PEWS and SBARD

Assessor____________________ Signature __________________ Status ___________ Date _______

Review Competent Health Care Verifier signature Comments

Dates: Yes / No Professional /
Assessor Signature

Appendix 4g
Levels of competency Rating Scale
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 Level of achievement Level
Novice Cannot perform this activity satisfactorily to the level 0
required in order to participate in the clinical environment
Can perform this activity but not without constant 1
supervision and assistance

Can perform this activity with a basic understanding of 2

theory and practice principles, but requires some
supervision and assistance
Competent Can perform this activity with understanding of theory 3
Practitioner and practice principles without assistance and/or direct
supervision
Can perform this activity with understanding of theory 4
and practice principles without assistance and/or direct
supervision, at an appropriate pace and adhering to
evidence based practice

At this level competence will have been maintained for at

least 6 months and/or is used frequently (2-3 times
/week) The practitioner will demonstrate confidence and
proficiency and show fluency and dexterity in practice
This is the minimum level required to be able to
assess practitioners as competent

Can perform this activity with understanding of theory 5

and practice principles without assistance and/or direct
supervision, at an appropriate pace and adhering to
evidence based practice.

At this level the practitioner will be able to adapt

knowledge and skill to special/ novel situations where
there may be increased levels of complexity and/or risk
Expert Can perform this activity with understanding of theory 6
and practice principles without assistance and/or direct
supervision, at an appropriate pace and adhering to
evidence based practice.
Demonstrate initiative and adaptability to special
problem situations, and can lead others in performing
this activity

At this level the practitioner is able to co-ordinate, lead

and assesses others who are assessing competence.
Ideally they will have a teaching and /or mentor
qualification

Adapted from: Herman GD, Kenyon RJ (1987) Competency-Based Vocational Education. A Case
Study, Shaftsbury, FEU, Blackmore Press, cited in Fearon, M. (1998) Assessment and measurement
of competence in practice, Nursing Standard 12(22), pp43-47.

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APPENDIX 5 - LEaD (Leadership, Education & Development) Training Needs Analysis (TNA)

If there are any training implications in your policy, please make an appointment with the LEAD department to complete the TNA before the policy goes
through the Trust policy approval process.

Strategic &
Training Recording
Frequency Course Length Delivery Method Trainer(s) Operational
Programme Attendance
Responsibility
Variable depending on
Physical Assessment Classroom or workplace
mode of delivery
and monitoring

Holistic Assessment
Clinical training team MLE Director of Nursing
and Care Once
One day
Developing skills to Lecture/group work
recognise and
respond to the
One day
unwell patient
Directorate Division Target Audience
Adult Mental Health
MH/LD/Specialised
Learning Disabilities
Services
Specialised Services
Adults
All clinical staff who attend Basic Life Support (BLS) or Immediate Life Support (ILS) should attend one of the
Older Persons Mental
ISD above courses
Health
Children and Families
Corporate All (HR, Finance,
Services Governance, Estates etc.)

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APPENDIX 6 - Southern Health NHS Foundation Trust:
Equality Impact Analysis Screening Tool

Equality Impact Assessment (or ‘Equality Analysis’) is a process of systematically analysing a new
or existing policy/practice or service to identify what impact or likely impact it will have on protected
groups.

It involves using equality information, and the results of engagement with protected groups and
others, to understand the actual effect or the potential effect of your functions, policies or
decisions. The form is a written record that demonstrates that you have shown due regard to the
need to eliminate unlawful discrimination, advance equality of opportunity and foster good
relations with respect to the characteristics protected by equality law.

For guidance and support in completing this form please contact a member of the Equality
and Diversity team.

Name of policy/service/project/plan: Physical Assessment and Monitoring Policy

Policy Number: SH CP 43
Department: Integrated Community Services, Mental Health and
Learning Disability
Lead officer for assessment: Kayode Osanaiye / Amit Malik
Steve Coopey / Simon Johnson
Date Assessment Carried Out: July 2012

1. Identify the aims of the policy and how it is implemented.

Key questions Answers / Notes

Briefly describe purpose of the policy This Policy is for all clinical staffs of Southern Health
including NHS Foundation Trust providing Physical Health
 How the policy is delivered and Assessment, Monitoring and Management in both In-
by whom Patient and Community settings.
 Intended outcomes

2. Consideration of available data, research and information

Monitoring data and other information involves using equality information, and the results of
engagement with protected groups and others, to understand the actual effect or the potential
effect of your functions, policies or decisions. It can help you to identify practical steps to tackle
any negative effects or discrimination, to advance equality and to foster good relations.

Please consider the availability of the following as potential sources:

 Demographic data and other statistics, including census findings

 Recent research findings (local and national)
 Results from consultation or engagement you have undertaken
 Service user monitoring data

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 Information from relevant groups or agencies, for example trade unions and
voluntary/community organisations
 Analysis of records of enquiries about your service, or complaints or compliments about
them
 Recommendations of external inspections or audit reports

Key questions Data, research and information

that you can refer to
2.1 What is the equalities profile of the team This Policy applies to ALL clinical
delivering the service/policy? staff.
2.2 What equalities training have staff received? All staff using this policy complies
with the mandatory requirements for
Equality and Diversity training.
2.3 What is the equalities profile of service users? Service users are able to access this
service as identified solely by clinical
need.
2.4 What other data do you have in terms of service This policy does not discriminate
users or staff? (e.g. results of customer against service users.
satisfaction surveys, consultation findings). Are
there any gaps?
2.5 What internal engagement or consultation has This policy and EIA will be circulated
been undertaken as part of this EIA and with to all key service providers before
whom? approval/ratification.
What were the results? Service
users/carers/Staff
2.6 What external engagement or consultation has
been undertaken as part of this EIA and with
whom?
What were the results? General
Public/Commissioners/Local Authority/Voluntary
Organisations

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In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any
potential negative impact on equality of opportunity for the target:

In the case of negative impact, please indicate any measures planned to mitigate against this:

Positive impact Negative Impact Action Plan to address negative impact

(including examples of what the
policy/service has done to
Actions to Resources Responsibility Target date
promote equality) overcome required
problem/barrier

Age

Disability Service users are

able to access this
Gender service as identified
Reassignment solely by clinical
needs and therefore
Marriage and this policy does not
Civil discriminate against
Partnership service users.
Pregnancy and
Maternity

Race
Religion or
Belief

Sex

Sexual
Orientation

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