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Clinical Assessment

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Return to: Patient Care

Return to: FHIR Patient Care Resources


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:
- 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)"
- 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
o Observations 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)
(~ 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




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



| ONC S&I Structured Data Capture Initiative is actively investigating representation of questionnaire content.