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.
- - 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
- - 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/