Encyclopedia of Database Systems

2018 Edition
| Editors: Ling Liu, M. Tamer Özsu

Clinical Observation

  • Dan Russler
Reference work entry
DOI: https://doi.org/10.1007/978-1-4614-8265-9_61

Synonyms

Clinical judgment; Clinical result; Clinical test; Finding of observation

Definition

  1. 1.

    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.

     
  2. 2.

    The result, answer, judgment, or knowledge gained from the act of observing a patient or a specimen from a patient in healthcare.

     

These two definitions of “observation” have caused confusion in clinical communications, especially when applying the term to the rigor of standardized terminologies. When developing a list of observations, the terminologists have differed on whether the list of terms should refer to the “act of observing” or the “result of the observation.”

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...

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Recommended Reading

  1. 1.
    Russler D, et al. Influences of the unified service action model on the HL7 reference information model. In: JAMIA Symposium Supplement, Proceedings SCAMC; 1999. p. 930–4.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Oracle Health SciencesRedwood ShoresUSA
  2. 2.Georgia Tech Research InstituteAtlantaUSA

Section editors and affiliations

  • Vipul Kashyap
    • 1
  1. 1.Director, Clinical ProgramsCIGNA HealthcareBloomfieldUSA