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Difference between revisions of "ClinicalAssessment FHIR Resource Proposal"

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=PutProposedResourceNameHere=
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=ClinicalAssessment=
  
<!-- Resource names should meet the following characteristics:
 
* Lower camel case
 
* U.S. English
 
* Domain-friendly
 
* Short
 
* Clear
 
* Unique
 
* Avoid non-universal abbreviations (e.g. URL would be ok)
 
* Be expressed as a noun
 
* Be consistent with other similar resources
 
-->
 
  
 
==Owning committee name==
 
==Owning committee name==
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==Contributing or Reviewing Work Groups==
 
==Contributing or Reviewing Work Groups==
  
<!-- Additional work groups that may have an interest in contributing to, or reviewing  the content of the resource (optional) -->
+
None"
* Work Group Name
 
* or link
 
* or "None"
 
  
 
==FHIR Resource Development Project Insight ID==
 
==FHIR Resource Development Project Insight ID==
  
<!-- Please specify the id of your work group’s PSS for doing FHIR work.  (If submitted but not yet approved, just write “pending”.) The link to the PSS template can be found here: http://gforge.hl7.org/gf/download/docmanfileversion/6832/9398/HL7FHIR_DSTUballotPSS-20120529.doc -->
+
Pending
  
 
==Scope of coverage==
 
==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 part of 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.
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:  
 
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?)
+
  * 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 assessment? (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?
 
* 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
 
* 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
Line 70: Line 45:
 
* Investigations - the specification needs a good value set for the code for the group, and will be considering the name "investigations" further
 
* Investigations - the specification needs a good value set for the code for the group, and will be considering the name "investigations" further
  
 +
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.
  
 +
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.
  
 
==RIM scope==
 
==RIM scope==
Line 78: Line 59:
 
==Resource appropriateness==
 
==Resource appropriateness==
  
<!-- Does the resource meet the following characteristics?
+
The concept of a 'clinical note' is fundamental to recording clinician/patient interactions. Given the wide variety of detail that is recorded, some a simple note to a complex, structured history & examination, some sort of 'backbone' to the recording is required. It will not contain the clinical information - it will link together all disparate resources required to document the interaction.
 
 
Must
 
* Represents a well understood, "important" concept in the business of healthcare
 
* Represents a concept expected to be tracked with distinct, reliable, unique ids
 
* Reasonable for the resource to be independently created, queried and maintained
 
 
 
Should
 
* Declared interest in need for standardization of data exchange</span>
 
* Resource is expected to contain an appropriate number of "core" (non-extension) data elements (in most cases, somewhere in the range of 20-50)
 
* Have the characteristics of high cohesion & low coupling – need to explore whether coupling is good some places, not elsewhere – layers from Bo’s document  
 
-->
 
  
 
==Expected implementations==
 
==Expected implementations==
  
<!--Key resources are justified by CCDA, for resources not deemed "key", what interest is there by implementers in using this particular resource. Provide named implementations if possible - ideally provide multiple independent implementations. -->
+
Any EMH/EHR that is recording the contact (physical or virtual) between a patient and a care deliverer (including clinician)
  
 
==Content sources==
 
==Content sources==
  
<!-- List all of the specifications (beyond those in the "standard" (FHIR_Design_Requirements_Sources) list of source specifications) that you’re planning to consult
+
CCDA, openEHR, existing systems, existing EMR/EHR systems
  
Are there any source specifications that you wish to consult but are concerned about access to or expertise to consider? -->
+
==Example Scenarios==
  
==Example Scenarios==
+
A patient is seen by a Primary care Provider with a sore throat. The symptoms & signs are recorded, and the investigations and treatment plans (including orders) are recorded.
  
<!-- Provide a listing of the types of scenarios to be represented in the examples produced for this resource. They should demonstrate the full scope of the resource and allow exercising of the resources capabilities (full element coverage, inclusion & omission of optional elements, repeating and singleton repeating elements, etc.) -->
+
A patient telephones the surgery for advice. The nurse records the patients symptoms and the advice given.
  
==Resource Relationships==
+
A patient attends a hospital clinical for investigation of hip pain.
  
There is another related clinical concept often called an "assessment": assessment Tools such as Apgar (also known as "Assessment Scales"),
+
A patient is reviewed in hospital during a 'Ward Round'.  
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.
 
  
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.
+
==Resource Relationships==
  
 +
Will be related to a number of resources - examples include Observation, Condition, Encounter, Patient, Practitioner, CarePlan
  
  

Revision as of 04:26, 5 March 2015



ClinicalAssessment

Owning committee name

Patient Care

Contributing or Reviewing Work Groups

None"

FHIR Resource Development Project Insight ID

Pending

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 part of 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 assessment? (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

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.

RIM scope

Resource appropriateness

The concept of a 'clinical note' is fundamental to recording clinician/patient interactions. Given the wide variety of detail that is recorded, some a simple note to a complex, structured history & examination, some sort of 'backbone' to the recording is required. It will not contain the clinical information - it will link together all disparate resources required to document the interaction.

Expected implementations

Any EMH/EHR that is recording the contact (physical or virtual) between a patient and a care deliverer (including clinician)

Content sources

CCDA, openEHR, existing systems, existing EMR/EHR systems

Example Scenarios

A patient is seen by a Primary care Provider with a sore throat. The symptoms & signs are recorded, and the investigations and treatment plans (including orders) are recorded.

A patient telephones the surgery for advice. The nurse records the patients symptoms and the advice given.

A patient attends a hospital clinical for investigation of hip pain.

A patient is reviewed in hospital during a 'Ward Round'.

Resource Relationships

Will be related to a number of resources - examples include Observation, Condition, Encounter, Patient, Practitioner, CarePlan


Timelines

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