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Observation, Clinical Assessment and Clinical Annotation

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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:
- Dictionary definition: "the act of watching somebody/something carefully for a period of time, especially to learn something"
- Source:


  • 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:

  • 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:

Clinical Assessment

Clinical Annotation