Clinical Assessment

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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

o Observations as determined by relevant systemic (e.g. CVS, respiratory, neurological) examination of the patient

o 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

• Nutrition Clinical Assessment Use Case 2014-10-30

• Head Injury Clinical Assessment Use Case: GCS 2014-10-15

• Acute Pharyngitis Clinical Assessment Use Case including clinical script updated 2014-11-05

• Rheumatoid Arthritis Clinical Assessment Use Case including clinical script updated 2014-11-03

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:

- http://wiki.hl7.org/index.php?title=Category:FHIR_Resource_Proposal

S&I Structured Data Capture Initiative is actively investigating representation of questionnaire content.