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  1. FHIR Specification Feedback
  2. FHIR-40153

Use of "Screening and Assessment" is misleading

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    Description

      The word assessment is commonly used in clinical practice and care and always brings confusion. This is because assessment is commonly used to mean both "observations" and "clinical judgement." Including "assessment" here does not help clarify the type of observation being made. As defined by Taber's Medical Dictionary assessment is "1. An appraisal or evaluation of a patient's condition by a physician, nurse, or other health care provider, based on clinical and laboratory data, medical history, and the patient's account of symptoms. 2. The process by which a patient's condition is appraised or evaluated." https://www.tabers.com/tabersonline/view/Tabers-Dictionary/751985/all/assessment#:~:text=1.,(%C4%83%2Dses%E2%80%B2m%C4%95nt)

      It appears the distinction that is being made for this type of observation is distinguish  a set of items (i.e. US Core Observation Screening Assessment Profile)  compared to a single item  (i.e. US Core Simple Observation Profile).  The set of items observed may be in the form of questions and answers as part of an interview/questionnaire or structured collection of test/activities the clinician has the patient perform or react to. Further clarity in identifying these profiles needs to be included and name appropriately.

      Consider renaming to Screening or Standardized Observation

      Reference [FHIR-39938|about:blank]

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            Matt_Elrod Matt Elrod
            Matt Elrod
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