ClinicalImpression

Clinical

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. This resource is called "ClinicalImpression" rather than "ClinicalAssessment" to avoid confusion with the recording of assessment tools such as Apgar score.

PathCard.TypeDescription & Constraints
ClinicalImpression0..*A clinical assessment performed when planning treatments and management strategies for a patient
.idΣ0..1StringLogical id of this artifact
.metaΣ0..1MetaMetadata about the resource
.implicitRules?!Σ0..1uriA set of rules under which this content was created
.language0..1codeLanguage of the resource content
Bindinglanguages(preferred)
.text0..1NarrativeText summary of the resource, for human interpretation
.contained0..*ResourceContained, inline Resources
.extension0..*ExtensionAdditional content defined by implementations
.modifierExtension?!0..*ExtensionExtensions that cannot be ignored
.identifierΣ0..*IdentifierBusiness identifier
.status?!Σ1..1codein-progress | completed | entered-in-error
Bindingclinicalimpression-status(required)
.statusReason0..1CodeableConceptReason for current status
BindingCodes identifying the reason for the current state of a clinical impression.(example)
.codeΣ0..1CodeableConceptKind of assessment performed
BindingIdentifies categories of clinical impressions. This is a place-holder only. It may be removed.(example)
.descriptionΣ0..1stringWhy/how the assessment was performed
.subjectΣ1..1Reference(Patient | Group)Patient or group assessed
.encounterΣ0..1Reference(Encounter)Encounter created as part of
.effective[x]Σ0..1dateTime | PeriodTime of assessment
.dateΣ0..1dateTimeWhen the assessment was documented
.assessorΣ0..1Reference(Practitioner | PractitionerRole)The clinician performing the assessment
.previous0..1Reference(ClinicalImpression)Reference to last assessment
.problemΣ0..*Reference(Condition | AllergyIntolerance)Relevant impressions of patient state
.investigation0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
.id0..1StringUnique id for inter-element referencing
.extension0..*ExtensionAdditional content defined by implementations
.modifierExtension?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.code1..1CodeableConceptA name/code for the set
Bindinginvestigation-sets(example)
.item0..*Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)Record of a specific investigation
.protocol0..*uriClinical Protocol followed
.summary0..1stringSummary of the assessment
.finding0..*BackboneElementPossible or likely findings and diagnoses
.id0..1StringUnique id for inter-element referencing
.extension0..*ExtensionAdditional content defined by implementations
.modifierExtension?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.itemCodeableConcept0..1CodeableConceptWhat was found
Bindingcondition-code(example)
.itemReference0..1Reference(Condition | Observation | Media)What was found
.basis0..1stringWhich investigations support finding
.prognosisCodeableConcept0..*CodeableConceptEstimate of likely outcome
Bindingclinicalimpression-prognosis(example)
.prognosisReference0..*Reference(RiskAssessment)RiskAssessment expressing likely outcome
.supportingInfo0..*Reference(Resource)Information supporting the clinical impression
.note0..*AnnotationComments made about the ClinicalImpression