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Clinical Assessment
Revision as of 01:47, 10 October 2014 by StephenChu (talk | contribs) (→Relevant Links and Documents)
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Contents
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 to develop a FHIR resource/profile to support the capturing and exchange of clinical assessment information.
Leadership
- Project co-leads:
- - Elaine Ayres
- - Stephen Chu
- - 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)"
Storyboards/Use Cases
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:
