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Clinical Assessment
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Return to: Patient Care
Goto to: Clinicians on FHIR
This page has been moved to https://confluence.hl7.org/display/PC/Clinical+Assessment
Contents
Background
Clinicians routinely perform clinical assessment to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition.
From a "problem-oriented" medical record structure perspective, the clinical assessment represents the "A" of the SOAP components.
This collaborative project is initiated to:
- determine the boundary and scope of "clinical assessment" and;
- develop a FHIR resource/profile to support the capturing and exchange of clinical assessment information.
Leadership
- Project co-leads:
- - Stephen Chu
- - Elaine Ayres
- - Russ Leftwich
- FHIR leads:
- - Lloyd McKenzie
- - David Hay
- Domain Experts:
- - Elaine Ayres
- - Stephen Chu
- - Russ Leftwich
- - Laura Heermann Langford
- - Kevin Coonan
- - Rob Hausam
- Stakeholder Groups:
- - Patient Care Workgroup
- - Orders & Observation
- - Clinical Decision Support
- - FHIR
Definitions
- Dictionary Definition:
- - Clinical assessment is "an evaluation of a patient's physical condition and prognosis based on information gathered from physical and laboratory examinations and the patient's medical history".
- - Source: http://medical-dictionary.thefreedictionary.com/clinical+assessment
- Definition (as discussed at 2014-10-09 conference call)"
- - Clinical assessment is defined as the "Process to arrive at the status (including the clinical impression of health risk or prognosis) of a patient constrained by their health concerns"
- - The process includes
- ~ The use of observation findings/results as determined by relevant systemic (e.g. CVS, respiratory, neurological) examination of the patient
- ~ Measurement or observation results from use of prescribed set of standardised assessment protocols/instruments (e.g. APGAR, Glasgow Coma Scale, Mini-Mental State Examination)
- (~ it is important to note that "assessment protocol/instrument" is part of the clinical assessment process and not the clinical assessment itself)
- - The actual observations represent the "S" and "O" of the SOAP documentation
- - The "A" in the SOAP is the documentation of the clinical analysis and reasoning or thought process based on the "S" and "O" findings of the patient's status
- - The assessment reflects the conclusion of the reasoning process (which also identifies how the conclusion was reached)
- Clinical Assessment Tool:
- - A clinical assessment tool is an instrument or a set of measurements designed to evaluate a patient's clinical condition and/or to predict the risk(s) or prognosis. The measurement parameters/variables may be organised/presented as questionnaire, checklist, or scale.
- - Examples:
- - Fracture Risk Assessment Tool (developed by the World Health Organisation Taskforce)
- - Standardized Mini Mental State Examination (SMMSE)
- - Barthel Index
- - International Resident Assessment Instrument (InterRAI)
Storyboards/Use Cases
- Contributors
- - Stephen Chu
- - Elaine Ayres
- - Russ Leftwich
Relevant Links and Documents
- Assessment Instruments and Guidelines:
- - Australia-Royal Children Hospital Cervical Spine Assessment Algorithm
- - Australia-Queensland Ambulance Service Clinical Assessment Procedures
- - Alcohol Withdrawal Assessment Scale
- Clinical Assessment FHIR Resource/Profile Proposal is available through this link:
S&I Structured Data Capture Initiative is actively investigating representation of questionnaire content.
