2. What the clinician must assess

A complete assessment addresses each of the following each visit, scaled to the patient's diagnosis and stability:

• The social support system — who is available, how reliably, and whether the support is adequate to the patient's needs.
• The primary caregiver — identity, capacity, competence, willingness, and the caregiver's own health.
• Caregiver strain or burden — signs of stress, exhaustion, or burnout.
• The patient's coping and adjustment to the illness.
• The social determinants of health — housing stability, food security, finances, transportation, and utilities.
• Access to resources and any unmet needs, and financial barriers to medications or care.
• Advance-care-planning and goals-of-care status, and cultural or spiritual factors affecting care.
• Isolation or loneliness, and indicators of abuse, neglect, or exploitation (mandated reporting is handled in Safety).