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+ | [[Category:Patient Care FHIR Resources and Extensions]] | ||
+ | Return to: [[Patient Care]] | ||
− | + | Goto to: [[Clinicians on FHIR]] | |
+ | |||
+ | '''This page has been moved to https://confluence.hl7.org/display/PC/Clinical+Assessment''' | ||
<br> | <br> | ||
=Background= | =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. | ||
<br> | <br> | ||
+ | |||
=Leadership= | =Leadership= | ||
* '''Project co-leads''': | * '''Project co-leads''': | ||
− | : Elaine Ayres | + | : - Stephen Chu |
− | : | + | : - Elaine Ayres |
− | + | : - Russ Leftwich | |
− | * '''FHIR leads''' | + | <br> |
+ | * '''FHIR leads''': | ||
: - Lloyd McKenzie | : - Lloyd McKenzie | ||
: - David Hay | : - David Hay | ||
<br> | <br> | ||
+ | * '''Domain Experts''': | ||
+ | : - Elaine Ayres | ||
+ | : - Stephen Chu | ||
+ | : - Russ Leftwich | ||
+ | : - Laura Heermann Langford | ||
+ | : - Kevin Coonan | ||
+ | : - Rob Hausam | ||
+ | |||
+ | <br> | ||
+ | |||
+ | * '''Stakeholder Groups''': | ||
+ | : - Patient Care Workgroup | ||
+ | : - Orders & Observation | ||
+ | : - Clinical Decision Support | ||
+ | : - FHIR | ||
+ | |||
+ | |||
+ | <br> | ||
+ | |||
=Definitions= | =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 | ||
+ | <br> | ||
+ | * '''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) | ||
+ | |||
+ | <br> | ||
+ | * '''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) | ||
<br> | <br> | ||
+ | |||
=Storyboards/Use Cases= | =Storyboards/Use Cases= | ||
+ | <br> | ||
+ | |||
+ | * '''Contributors''' | ||
+ | : - Stephen Chu | ||
+ | : - Elaine Ayres | ||
+ | : - Russ Leftwich | ||
+ | <br> | ||
+ | |||
+ | * [[Media:Clinical-Assessment-Use-Case_2014-10-30_final.docx|Nutrition Clinical Assessment Use Case 2014-10-30]] | ||
+ | |||
+ | |||
+ | * [[Media:Clinical-Assessment-Use-Case_2014-10-15_Head-Injury.docx|Head Injury Clinical Assessment Use Case: GCS 2014-10-15]] | ||
+ | |||
+ | * [[Media:Clinical-Assessment-Use-Case_2014-11-05_AcutePharyngitis_v02a.docx|Acute Pharyngitis Clinical Assessment Use Case including clinical script updated 2014-11-05]] | ||
+ | |||
+ | |||
+ | * [[Media:Clinical-Assessment-Use-Case_2014-11-03_Rheumatoid-Arthritis_v03.docx|Rheumatoid Arthritis Clinical Assessment Use Case including clinical script updated 2014-11-03]] | ||
+ | |||
+ | |||
+ | <br> | ||
+ | |||
+ | =Relevant Links and Documents= | ||
+ | <br> | ||
+ | * '''Assessment Instruments and Guidelines''': | ||
+ | : - [[Media:Cervical-Spine-Assessment-Algorithm_RCH-Australia.pdf|Australia-Royal Children Hospital Cervical Spine Assessment Algorithm]] | ||
+ | : - [[Media:Clinical-Procedure-Assessments_Ambulance-Qld.pdf|Australia-Queensland Ambulance Service Clinical Assessment Procedures]] | ||
+ | : - [[Media:Alcohol-Withdrawal-Assessment-Scale.pdf|Alcohol Withdrawal Assessment Scale]] | ||
<br> | <br> | ||
− | = | + | * '''Clinical Assessment FHIR Resource/Profile Proposal is available through this link''': |
+ | : - http://wiki.hl7.org/index.php?title=Category:FHIR_Resource_Proposal | ||
<br> | <br> | ||
+ | [http://wiki.siframework.org/Structured+Data+Capture+Initiative|ONC S&I Structured Data Capture Initiative] is actively investigating representation of questionnaire content. |
Latest revision as of 23:10, 9 November 2018
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.