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Difference between revisions of "ClinicalAssessment FHIR Resource Proposal"

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(Created page with "{{subst::Template:FHIR Resource Proposal}}")
 
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==Owning committee name==
 
==Owning committee name==
  
<!-- The name of the committee that is proposed to have responsibility for developing and maintaining the resources. -->
+
[[Patient Care]]
[[YourCommitteeName]]
 
  
 
==Contributing or Reviewing Work Groups==
 
==Contributing or Reviewing Work Groups==
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==Scope of coverage==
 
==Scope of coverage==
  
<!-- Define the full scope of coverage for the resource.  The scope must be clearly delineated such that it does not overlap with any other existing or expected resource.  The scope will be used to govern "what is the set of potential applications to consider when evaluating what elements are 'core' – i.e. in the 80%"
 
  
Scope should consider numerous aspects of breadth of scope, including:
 
* Subject: Human vs. non-human vs. non-patient (e.g. lab bench medicine)
 
* Disciplines: Environmental Health, Palliative, Respiratory, Psychology, Maternity, Clinical Research
 
* Delivery environment (Community, Geriatric, Home care, Emergency, Inpatient, Intensive, Neonatal, Pediatric, Primary)
 
* Locale: Country, region
 
  
As a rule, resources should encompass all of these aspects.
+
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. &quot;Progress satisfactory,
 +
continue with treatment&quot;), 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
 +
 
 +
 
  
 
==RIM scope==
 
==RIM scope==
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==Resource Relationships==
 
==Resource Relationships==
  
<!-- What are the resources do you expect will reference this resource and in what context?
+
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 &quot;clinical assessment&quot; 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.
  
What resources do you expect this resource reference and in what context?
+
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.
  
Note: These may be existing resources or "expected" resource
 
  
Reference to resources is really only relevant at the "same or higher level" (Bo – fix this wording)
 
-->
 
  
 
==Timelines==
 
==Timelines==

Revision as of 04:09, 5 March 2015



PutProposedResourceNameHere

Owning committee name

Patient Care

Contributing or Reviewing Work Groups

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

FHIR Resource Development Project Insight ID

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


RIM scope

Resource appropriateness

Expected implementations

Content sources

Example Scenarios

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.


Timelines

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