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Difference between revisions of "Clinical Assessment"

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Return to: [[Patient Care]]
 
Return to: [[Patient Care]]
  
Return to: [[FHIR Patient Care Resources]]   
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Goto to: [[Clinicians on FHIR]]   
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'''This page has been moved to https://confluence.hl7.org/display/PC/Clinical+Assessment'''
  
 
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* '''Project co-leads''':
 
* '''Project co-leads''':
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: - Stephen Chu
 
: - Elaine Ayres
 
: - Elaine Ayres
: - Stephen Chu
 
 
: - Russ Leftwich
 
: - Russ Leftwich
  
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: - 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"
 
: - 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 process includes
:: o Observations as determined by relevant systemic (e.g. CVS, respiratory, neurological) examination of the patient
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:: ~ The use of observation findings/results 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)
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:: ~ 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)
 
::: (~ 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 actual observations represent the "S" and "O" of the SOAP documentation
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=Storyboards/Use Cases=
 
=Storyboards/Use Cases=
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* '''Contributors'''
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: - Stephen Chu
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: - Elaine Ayres
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: - Russ Leftwich
 
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* [[Media:Clinical-Assessment-Use-Case_2014-10-30_final.docx|Nutrition Clinical Assessment Use Case 2014-10-30]]
 
* [[Media:Clinical-Assessment-Use-Case_2014-10-30_final.docx|Nutrition Clinical Assessment Use Case 2014-10-30]]
  
* [[Media:Clinical-Assessment-Use-Case_2014-10-25_Rheumatoid-Arthritis_v03.docx|Rheumatoid Arthritis Clinical Assessment Use Case including clinical script updated 2014-10-25]]
 
  
 
* [[Media:Clinical-Assessment-Use-Case_2014-10-15_Head-Injury.docx|Head Injury Clinical Assessment Use Case: GCS 2014-10-15]]
 
* [[Media:Clinical-Assessment-Use-Case_2014-10-15_Head-Injury.docx|Head Injury Clinical Assessment Use Case: GCS 2014-10-15]]
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* [[Media:Clinical-Assessment-Use-Case_2014-11-05_AcutePharyngitis_v02a.docx|Acute Pharyngitis Clinical Assessment Use Case including clinical script updated 2014-11-05]]
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* [[Media:Clinical-Assessment-Use-Case_2014-11-03_Rheumatoid-Arthritis_v03.docx|Rheumatoid Arthritis Clinical Assessment Use Case including clinical script updated 2014-11-03]]
  
  
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[http://wiki.siframework.org/Structured+Data+Capture+Initiative |ONC S&I Structured Data Capture Initiative] is actively investigating representation of questionnaire content.
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[http://wiki.siframework.org/Structured+Data+Capture+Initiative|ONC S&I Structured Data Capture Initiative] is actively investigating representation of questionnaire content.

Latest revision as of 23:10, 9 November 2018


Return to: Patient Care

Goto to: Clinicians on FHIR

This page has been moved to https://confluence.hl7.org/display/PC/Clinical+Assessment


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
~ 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)


Storyboards/Use Cases


  • Contributors
- Stephen Chu
- Elaine Ayres
- Russ Leftwich







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.