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Difference between revisions of "Observation, Clinical Assessment and Clinical Annotation"

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=Observation=
 
=Observation=
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* '''Observation''':
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: - Dictionary definition: "the act of watching somebody/something carefully for a period of time, especially to learn something"
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: - Source: http://www.oxfordlearnersdictionaries.com/definition/english/observation
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<br>
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===Definitions===
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* '''Clinical''':
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: - Dictionary definitions:
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:: -  Relating to the bedside treatment of a patient or to the course of the disease
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:: -  Relating to the observed symptoms and course of a disease
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: - Source: http://medical-dictionary.thefreedictionary.com/clinical
  
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<br>
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* '''Clinical observation''':
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: - Definition: "the act of watching and obtaining information about a patient's clinical status including signs, symptoms, and course of a disease"
  
 
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* '''Examples of clinical observations''':
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: - "Clinical observations include estimation of haemoglobin-oxygen saturation (SpO2, pulse oximetry), oxygen therapy, respiratory rate, heart/pulse rate, blood pressure (systolic, diastolic and mean), temperature (including measurement method), sedation and pain. In certain clinical circumstances further observations (for example neurological) may be required"
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: - Source: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Observation_and_Continuous_Monitoring/
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=Clinical Assessment=
 
=Clinical Assessment=
  

Revision as of 23:53, 1 January 2015

Return to: Patient Care

Return to: FHIR Patient Care Resources


Background


An email in mid December 2014 raised the question of clinical annotation:

"Is it ClinicalAssessment the best way to model a clinical annotation instead of Observation?"


A number of email exchanges that followed showed the non clinical community appeared to have considerable confusion over the three concepts: observation, clinical assessment and annotation.

This wiki page is intended to provide some clarity from the clinical perspectives to help resolve the confusion.


Observation


  • Observation:
- Dictionary definition: "the act of watching somebody/something carefully for a period of time, especially to learn something"
- Source: http://www.oxfordlearnersdictionaries.com/definition/english/observation


Definitions


  • Clinical:
- Dictionary definitions:
- Relating to the bedside treatment of a patient or to the course of the disease
- Relating to the observed symptoms and course of a disease
- Source: http://medical-dictionary.thefreedictionary.com/clinical


  • Clinical observation:
- Definition: "the act of watching and obtaining information about a patient's clinical status including signs, symptoms, and course of a disease"


  • Examples of clinical observations:
- "Clinical observations include estimation of haemoglobin-oxygen saturation (SpO2, pulse oximetry), oxygen therapy, respiratory rate, heart/pulse rate, blood pressure (systolic, diastolic and mean), temperature (including measurement method), sedation and pain. In certain clinical circumstances further observations (for example neurological) may be required"
- Source: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Observation_and_Continuous_Monitoring/




Clinical Assessment


Clinical Annotation