MyCLHA
LPNs
Observation, Assessment, and Diagnosis
Information for Health Care Aides
Healthcare providers such as Health Care Aides (HCAs), Licensed Practical Nurses (LPNs), and physicians perform different activities in client care. This article describes the difference between observation, assessment, and diagnosis.
HCAs perform client observations as part of their role within a healthcare team. HCAs are not authorized to perform assessments or diagnoses.
Observation
Observation involves using sight, hearing, smell, and touch to monitor changes in a client’s health or social well-being.
HCAs spend a lot of time with clients, so other regulated health professionals, such as nurses, often rely on HCAs to communicate changes observed in a client’s behaviour or health condition during their day-to-day care. This collaboration ensures that information reaches the authorized health professional in a timely manner for further assessment.
Examples of Observations
- vital sign readings such as breathing rate, blood pressure, pulse, and temperature;
- intake/output measurement;
- blood in the urine or stool;
- swallowing difficulty;
- changes in the client’s behaviour or health status;
- any unexpected adverse events, including rashes and allergic reactions; and
- unsafe conditions or environment.
If a client’s condition is observed to be abnormal or outside the client’s baseline, the HCA should immediately report this to a supervising health professional such as a nurse so that an assessment can be performed.
Assessment
HCAs do not perform client assessments. Only authorized health professionals, such as nurses, psychologists, or occupational therapists, can perform client assessments.
When an HCA reports changes in a client condition to a nurse, that nurse will perform a nursing assessment. A nursing assessment involves using the client’s gathered health information to understand their overall health, symptoms, and concerns. This process includes evaluating the client’s individual physiological, psychological, sociological, and spiritual needs.
Diagnosis
A medical diagnosis identifies a disease, injury, or condition based on presenting signs and symptoms. Authorized health professionals like physicians, nurse practitioners, dentists, and physician assistants conduct this process by investigating observations, performing assessments, and ordering diagnostic tests to tell one condition from others. Diagnosis aims to determine the cause of a client’s symptoms (e.g., pneumonia, diabetes) and guides the treatment plan and medical interventions.
HCAs are not authorized to make a medical diagnosis.
Summary
The following table is found on page 3-4 of the HCA info sheet, Understanding the Difference Between Diagnosing, Assessing, and Observing. It summarizes the differences between observation, assessment, and diagnosis.
| Observation | Assessment | Diagnosis | |
| Purpose | To monitor and detect changes or abnormal findings in the client’s state or condition. The information gathered helps inform the next steps in the client’s healthcare journey. | To learn more about the client’s overall health, symptoms, and concerns. | To identify a disease or condition. |
| Information collected | Objective and subjective data on the client’s condition, such as:
|
Detailed information from the client’s health history, test results, assessment, etc., including observations and the client’s individual physiological, psychological, sociological, and spiritual needs. | The information collected during observation and assessment, together with the client’s physical, mental, and psychosocial conditions. |
| Who can perform it | A range of trained health professionals, including HCAs. | Health professionals with specific skills, knowledge, critical thinking, and clinical judgment, such as nurses or physicians. HCAs are not authorized to conduct assessments. | Specific health professionals authorized by law to diagnose. Examples are doctors, NPs, optometrists, and physician assistants. HCAs are not authorized to make a diagnosis. |
| Outcome | Contributes to continuity of care and holistic care by providing information related to changes in the client’s condition that can be further investigated. | Evaluates information to make a diagnosis and/or develop or update a client’s care plan. It may also inform the next steps in the treatment or discharge plan. | Identifies a disease, condition, or injury, which helps health professionals determine a treatment plan, track progression, and understand the prognosis. |