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"
- - 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:
- 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)