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:


Project co-leads:

FHIR leads:

- Lloyd McKenzie
- David Hay

Domain Experts:

Stakeholder Groups:

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


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". 


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

Clinical Assessment Tool:

Storyboards / Use Cases



Progress and Related Work

Relevant Links and Documents

Assessment Instruments and Guidelines:

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