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

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For more details see:
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: * [[Observation vs Condition]]
  

Revision as of 00:05, 2 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"
- HL7 Perspective:
In HL7 the "observation" ACT is actually the "act of documenting results of observation"; as such, the value that is captured in the HL7 observation is semantically equivalent to "observation result"


  • 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/


For more details see:

* Observation vs Condition


Clinical Assessment


Clinical Annotation