clinical observation

What is clinical observation?

clinical observation is Clinical information, excluding information about treatment and intervention. Clinical information that does not record an intervention is by nature a clinical observation. The observer may be the patient or related person (information about symptoms, family history, occupation or lifestyle) or a health care professional (information about physical signs, measurements, properties observed or diagnoses). While information about the nature of a planned or performed treatment is excluded by the definition, clinical observations may be recorded on the results of a treatment, on progress during the course of a treatment, or on the result of a treatment.

 

source: A GLOSSARY OF TERMS FOR COMMUNITY HEALTH CARE AND SERVICES FOR OLDER PERSONS. World Health Organization, 2004.

Tags: