The act of measuring, questioning, evaluating, or otherwise observing a patient or a specimen from a patient in healthcare; the act of making a clinical judgment.
The result, answer, judgment, or knowledge gained from the act of observing a patient or a specimen from a patient in healthcare.
Logical Observation Identifiers Names and Codes (LOINC) (www.loinc.org) focus on observation as the “act of observing.” Systematized Nomenclature of Medicine (SNOMED) (www.ihtsdo.org) asserts that “General finding of observation of patient” is a synonym for “General observation of patient.” Of note is the analysis in HL7 that identifies many shared attributes between descriptions of the act of observing and the result obtained. As a consequence, in HL7 Reference Information Model (RIM), both the act of observing and the result of the observation are contained in the same Observation Class (www.hl7.org).
The topic of clinical observation has been central to the study of medicine since medicine began. Early physicians focused on the use of all five senses in order to make judgments about the current condition of the patient, i.e., diagnosis, or to make judgments about the future of patients, i.e., prognosis. Physical exam included sight, touch, listening, and smell. Physicians diagnosed diabetes by tasting the urine for sweetness.
As more tests on bodily fluids and tissues were discovered and used, the opportunity for better diagnosis and prognosis increased. Philosophy of science through the centuries often included the study of clinical observation in addition to the study of other observations in nature.
During the last century, the study of rigorous testing techniques that improve the reproducibility and interpretation of results has included the development of extensive nomenclatures for naming the acts of observation and observation results, e.g., LOINC and SNOMED. These terminologies were developed in part to support the safe application of expert system rules to information recorded in the electronic health care record.
The development of the HL7 Reference Information Model (RIM) was based on analysis of the “act of observing” and the “result of the act of observing” . Today, new Entity attributes proposed for the HL7 RIM are evaluated for inclusion based partly on whether the information is best communicated in a new attribute for an HL7 Entity or best communicated in an HL7 Observation Act.
Improved standardization of clinical observation techniques, both in the practice of bedside care and the recording of clinical observations in electronic healthcare systems is thought to be essential to the continuing improvement of healthcare and patient safety.