2. What the clinician must assess

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

• General appearance, grooming, and hygiene, and any change in self-care.
• Level of distress — none, mild, moderate, or severe — and apparent acuity.
• Apparent nutritional and hydration status (the detailed assessment lives in Nutrition and Hydration).
• Alertness, orientation to interaction, and engagement (the detailed cognitive assessment lives in the Cognitive module).
• Constitutional symptoms — fever or chills, fatigue or malaise, unintentional weight loss or gain, appetite change, and night sweats.
• Functional status and any change from baseline.
• Overall stability versus baseline, and whether the findings cluster into a recognizable pattern (infection, decompensation, or deterioration).