A record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition. Assessments are often 1:1 with a clinical consultation / encounter, but this varies greatly depending on the clinical workflow.

The patient being asssesed.

The clinicial performing the assessment.

The point in time at which the assessment was concluded (not when it was recorded).

This SHOULD be accurate to at least the minute, though some assessments only have a known date.

A summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/sstatus prompted it.

A reference to the last assesment that was conducted bon this patient. Assessments are often/usually ongoing in nature; a care provider (practitioner or team) will make new assessments on an ongoing basis as new data arises or the patient's conditions changes.

It is always likely that multiple previous assessments exist for a patient. The point of quoting a previous assessment is that this assessment is relative to it (see resolved).

This a list of the general problems/conditions for a patient.

e.g. The patient is a pregnant, and cardiac congestive failure, ‎Adenocarcinoma, and is allergic to penicillin.

A reference to a specific care plan that prompted this assessment. The care plan provides further context for the assessment.

A reference to a specific care plan that prompted this assessment. The referral request may provide further context for the assessment.

One or more sets of investigations (signs, symptions, etc). The actual grouping of investigations vary greatly depending on the type and context of the assessment. These investigations may include data generated during the assessment process, or data previously generated and recorded that is pertinent to the outcomes.

A name/code for the group ("set") of investigations. Typically, this will be something like "signs", "symptoms", "clinical", "diagnostic", but the list is not constrained, and others such groups such as (exposure|family|travel|nutitirional) history may be used.

A record of a specific investigation that was undertaken.

Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used.

Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.

A text summary of the investigations and the diagnosis.

An specific diagnosis that was considered likely or relevant to ongoing treatment.

Specific text of code for diagnosis.

Which investigations support diagnosis.

Diagnoses/conditions resolved since the last assessment.

Diagnosis considered not possible.

Specific text of code for diagnosis.

Grounds for elimination.

Estimate of likely outcome.

Plan of action after assessment.

Actions taken during assessment.