Observation, Clinical Assessment and Clinical Annotation

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Background

An email in mid December 2014 raised the question of clinical annotation:

"Is it ClinicalAssessment the best way to model a clinical annotation instead of Observation?"

A number of email exchanges that followed showed the non clinical community appeared to have considerable confusion over the three concepts: observation, clinical assessment and annotation.

This wiki page is intended to provide some clarity from the clinical perspectives to help resolve the confusion.

Observation

Definitions

• Observation:

- Dictionary definition: "the act of watching somebody/something carefully for a period of time, especially to learn something"

- Source: http://www.oxfordlearnersdictionaries.com/definition/english/observation

• Clinical:

- Dictionary definitions:

- Relating to the bedside treatment of a patient or to the course of the disease

- Relating to the observed symptoms and course of a disease

- Source: http://medical-dictionary.thefreedictionary.com/clinical

• Clinical observation:

- Definition:

"the act of watching and obtaining information about a patient's clinical status including signs, symptoms, and course of a disease"

- HL7 Perspective:

In HL7 the "observation" ACT is actually the "act of documenting results of observation"; as such, the value that is captured in the HL7 observation is semantically equivalent to "observation result"

Examples of clinical observations

• "Clinical observations [examples] include estimation of:

- haemoglobin-oxygen saturation (SpO2, pulse oximetry), oxygen therapy

- respiratory rate

- heart/pulse rate

- blood pressure (systolic, diastolic and mean)

- temperature (including measurement method)

- sedation and pain levels.

In certain clinical circumstances further observations (for example neurological) may be required"

- Source: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Observation_and_Continuous_Monitoring/

Related Topic

• Observation vs Condition

Clinical Assessment

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)

Examples of Clinical Assessment

• Clinical Assessment of Chest Pain:

- The clinical assessment of pain includes the following:

~ Aetiology of pain (e.g. mechanism of injury), if identifiable (clinical history, physical examination: Observation)

~ Location/distribution of pain (Observation)

~ Severity/magnitude (use of pain assessment scales: Observation

~ Quality/characteristic (Observation)

~ Contributing/aggravating/associated factors (clinical history, physical examination: Observation)

~ relieving factors (clinical history, physical examination: Observation)

~ ECG/EKG findings

~ Blood test (cardiac enzymes) results

~ X-ray chest findings (where appropriate)

~ Family history (Observation)

~ Clinical reasoning (assessment): how likely is this a case of

- acute myocardial infarction?

- pleurisy?

- indigestion

~ Result of clinical reasoning:

- diagnosis

- differential diagnosis

Related Topic

• Clinical Assessment (including clinical storyboards)

Clinical Annotation

Definitions

• Dictionary Definition of Annotation:

- "A note by way of explanation or comment added to a text or diagram"

- "The act or process of furnishing commentary or explanatory notes"

- "An annotation is metadata (e.g. a comment, explanation, presentational markup) attached to text, image, or other data"

• Clinical Annotation:

- A note or commentary added to a patient's clinical information (document or image) to explain or add new information. A note or commentary may also be added to correct a previously recorded information.

- Note: Annotation of clinical information is a relatively common practice in the paper clinical record. The annotation is initialized or signed by the person who adds the annotation