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Clinical Assessment

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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.


  • 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


  • 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:

  • 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.