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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"
- 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 [examples] 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 levels.
In certain clinical circumstances further observations (for example neurological) may be required"
- Source:

Related Topic

Clinical Assessment


  • 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:

  • 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
~ The use of observation findings/results as determined by relevant systemic (e.g. CVS, respiratory, neurological) examination of the patient
~ Measurement or observation results from 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)

Examples of Clinical Assessment

  • Clinical Assessment of Chest Pain:
- The clinical assessment of pain includes the following:
~ Aetiology of pain (e.g. mechanism of injury), if identifiable (clinical history, physical examination: Observation)
~ Location/distribution of pain (Observation)
~ Severity/magnitude (use of pain assessment scales: Observation
~ Quality/characteristic (Observation)
~ Contributing/aggravating/associated factors (clinical history, physical examination: Observation)
~ relieving factors (clinical history, physical examination: Observation)
~ ECG/EKG findings
~ Blood test (cardiac enzymes) results
~ X-ray chest findings (where appropriate)
~ Family history (Observation)
~ Clinical reasoning (assessment): how likely is this a case of
- acute myocardial infarction?
- pleurisy?
- indigestion
~ Result of clinical reasoning:
- diagnosis
- differential diagnosis

Related Topic

Clinical Annotation


  • Dictionary Definition of Annotation:
- "A note by way of explanation or comment added to a text or diagram"
- "The act or process of furnishing commentary or explanatory notes"
- "An annotation is metadata (e.g. a comment, explanation, presentational markup) attached to text, image, or other data"

  • Clinical Annotation:
- A note or commentary added to a patient's clinical information (document or image) to explain or add new information. A note or commentary may also be added to correct a previously recorded information.
- Note: Annotation of clinical information is a relatively common practice in the paper clinical record. The annotation is initialized or signed by the person who adds the annotation. A radiologist may also annotate a diagnostic image/imaging report.