: Public Note
Created: 1/26/2011 10:30:52 AM
Modified: 5/31/2011 9:51:05 AM
Project:
Advanced:
An assessment may include information that a clinician observes directly in the patient (e.g., skin color), information observed in a device (e.g., vitals), and information retrieved from a record (e.g., medications).<br /></p><p><br /></p><p>An observation may also be conditional, as when a chart datum (e.g., bmi) affects the method or interpretation of a direct observation (e.g., cuff size).<br /></p>