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Background

Clinicians routinely perform clinical assessment to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition.

From a "problem-oriented" medical record structure perspective, the clinical assessment represents the "A" of the SOAP components.

This collaborative project is initiated to:

  • determine the boundary and scope of "clinical assessment" and;
  • develop a FHIR resource/profile to support the capturing and exchange of clinical assessment information.

Leadership


Project co-leads:

  • Dr Stephen Chu
  • Dr Russ Leftwich
  • Elaine Ayres 


FHIR leads:

- Lloyd McKenzie
- David Hay

Domain Experts:

  • Stephen Chu
  • Russ Leftwich
  • Laura Heermann Langford
  • Emma Jones
  • Rob Hausam
  • Elaine Ayres
  • Kevin Coonan 

Stakeholder Groups:

- Patient Care Workgroup
- Orders & Observation
- Clinical Decision Support
- FHIR

Definitions

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

  • 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)
    • C-CDA Assessment Scale Template 
    • SDC - Structure Data Capture (SCD FHIR IG)
    • FHIR Clinical Guidelines - Library Resources
    • IHE Assessment Curation and Data Collection (ACDC - new profile in progress) - Assessment instruments curation and management

Storyboards / Use Cases

Contributors

  • Stephen Chu
  • Elaine Ayres
  • Russ Leftwich

Storyboards:

Progress and Related Work

  • Work on Clinical Assessment is continued as the FHIR ClinicalImpression Resource development

Relevant Links and Documents

Assessment Instruments and Guidelines:

Clinical Assessment FHIR Resource/Profile Proposal is available through this link:



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