ClinicalAssessment FHIR Resource Proposal

PutProposedResourceNameHere

Owning committee name

Patient Care

Contributing or Reviewing Work Groups

• Work Group Name
• or link
• or "None"

Scope of coverage

Performing a clinical assessment is a fundamental part of a clinician's workflow, performed repeatedly throughout the day. In spite of this - or perhaps, because of it - there is wide variance in how clinical assessments are recorded. Some clinical assessments simply result in a single text note in the patient 'record' (e.g. "Progress satisfactory, continue with treatment"), while others are associated with careful, detailed record keeping of the evidence gathered, the reasoning leading to a differential diagnosis, and the actions taken during or planned as a result of the clinical assessment, and there is a continuum between these. This resource is intended to be used to cover all these use cases.

The assessment is intimately linked to the process of care. It may occur in the context of a care plan, and it very often results in a new (or revised) care plan. Normally. clinical assessments are partof an ongoing process of care, and the patient will be re-assessed repeatedly. For this reason, the clinical assessment can explicit reference both care plans (preceeding and resulting) and reference a previous assessment that this assessment follows on from.

Unlike many other resources, there is little prior art with regard to exchanging records of clinical assessments. For this reason, this resource should be regarded as particularly prone to ongoing revision. In terms of scope and usage, the Patient Care workgroup wishes to draw the attention of reviewers and implementers to the following issues:

* When is an existing clinical assessment revised, rather than a new one created (that references the existing one)? How does that affect the status? what's the interplay between the status of the diagnosis and the status of the assesment? (e.g. for a 'provisional' assessment, which bit is provisional?)

• This structure doesn't differentiate between a working and a final diagnosis. Given an answer to the previous question, should it?
• Further clarify around the relationship between care plan and assessment is needed. Both answers to the previous questions and ongoing discussions around revisions to the care plan will influence the design of clinical assessment
• Should prognosis be represented, and if so, how much structure should it have?
• Should an assessment reference other assessments that are related? (how related?)
• Investigations - the specification needs a good value set for the code for the group, and will be considering the name "investigations" further

Resource Relationships

There is another related clinical concept often called an "assessment": assessment Tools such as Apgar (also known as "Assessment Scales"), and this is different to the scope of the "clinical assessment" resource. Assessment tools such as Apgar are represented as Observations, and Questionnaires may be used to help generate these. Clinical Assessments will often refer to these assessment tools as one of the investigations that was performed during the assessment process.

An important background to understanding this resource is the FHIR wiki page for clinical assessment. In particular, the storyboards there drove the design of the resource, and will be the basis for all examples created.