DSTU2 STU 3 Candidate
This page is part of the FHIR Specification (v1.0.2: DSTU 2). The current version which supercedes this version is

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . For a full list of available versions, see the Directory of published versions . Page versions: . Page versions: R5 R4B R4 R3 R2

4.6 4.8 Resource ClinicalImpression - Content Resource ClinicalImpression - Content

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.
Patient Care Patient Care Work Group Work Group Maturity Level : 0 Maturity Level : 0 Compartments : : Patient , , Practitioner

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.

4.6.1 Scope and Usage 4.8.1 Scope and Usage Performing a clinical assessment is a fundamental part of a clinician's workflow, performed repeatedly throughout the day. In spite of this - or perhaps, because of it - there is wide variance in how clinical impressions are recorded. Some clinical assessments simply result in an impression recorded as a single text note in the patient 'record' (e.g. "Progress satisfactory, continue with treatment"), while others are associated with careful, detailed record keeping of the evidence gathered, the reasoning leading to a differential diagnosis, and the actions taken during or planned as a result of the clinical assessment, and there is a continuum between these. This resource is intended to be used to cover all these use cases. The assessment is intimately linked to the process of care. It may occur in the context of a care plan, and it very often results in a new (or revised) care plan. Normally. clinical assessments are part of an ongoing process of care, and the patient will be re-assessed repeatedly. For this reason, the clinical impression can explicit reference both care plans (preceeding and resulting) and reference a previous impression that this impression follows on from. DSTU Note: Unlike many other resources, there is little prior art with regard to exchanging records of clinical assessments. For this reason, this resource should be regarded as particularly prone to ongoing revision. In terms of scope and usage, the Patient Care workgroup wishes to draw the attention of reviewers and implementers to the following issues: When is an existing clinical impression revised, rather than a new one created (that references the existing one)? How does that affect the status? what's the interplay between the status of the diagnosis and the status of the impression? (e.g. for a 'provisional' impression, which bit is provisional?) This structure doesn't differentiate between a working and a final diagnosis. Given an answer to the previous question, should it? Further clarify around the relationship between care plan and impression is needed. Both answers to the previous questions and ongoing discussions around revisions to the care plan will influence the design of clinical impression Should prognosis be represented, and if so, how much structure should it have? Should an impression reference other impressions that are related? (how related?) Investigations - the specification needs a good value set for the code for the group, and will be considering the name "investigations" further Feedback is welcome here

Performing a clinical assessment is a fundamental part of a clinician's workflow, performed repeatedly throughout the day. In spite of this - or perhaps, because of it - there is wide variance in how clinical impressions are recorded. Some clinical assessments simply result in an impression recorded as a single text note in the patient 'record' (e.g. "Progress satisfactory, continue with treatment"), while others are associated with careful, detailed record keeping of the evidence gathered, the reasoning leading to a differential diagnosis, and the actions taken during or planned as a result of the clinical assessment, and there is a continuum between these. This resource is intended to be used to cover all these use cases.

The assessment is intimately linked to the process of care. It may occur in the context of a care plan, and it very often results in a new (or revised) care plan. Normally. clinical assessments are part of an ongoing process of care, and the patient will be re-assessed repeatedly. For this reason, the clinical impression can explicit reference both care plans (preceeding and resulting) and reference a previous impression that this impression follows on from.

DSTU Note: Unlike many other resources, there is little prior art with regard to exchanging records of clinical assessments. For this reason, this resource should be regarded as particularly prone to ongoing revision. In terms of scope and usage, the Patient Care workgroup wishes to draw the attention of reviewers and implementers to the following issues:

  • When is an existing clinical impression revised, rather than a new one created (that references the existing one)? How does that affect the status? what's the interplay between the status of the diagnosis and the status of the impression? (e.g. for a 'provisional' impression, which bit is provisional?)
  • This structure doesn't differentiate between a working and a final diagnosis. Given an answer to the previous question, should it?
  • Further clarify around the relationship between care plan and impression is needed. Both answers to the previous questions and ongoing discussions around revisions to the care plan will influence the design of clinical impression
  • Should prognosis be represented, and if so, how much structure should it have?
  • Should an impression reference other impressions that are related? (how related?)
  • Investigations - the specification needs a good value set for the code for the group, and will be considering the name "investigations" further

Feedback is welcome here . .

4.6.2 Boundaries and Relationships 4.8.2 Boundaries and Relationships There is another related clinical concept often called an "assessment": assessment Tools such as Apgar (also known as "Assessment Scales"). This is not what the ClinicalImpression resource is about; assessment tools such as Apgar are represented as

There is another related clinical concept often called an "assessment": assessment Tools such as Apgar (also known as "Assessment Scales"). This is not what the ClinicalImpression resource is about; assessment tools such as Apgar are represented as Observations , and , and Questionnaires may be used to help generate these. Clinical Impressions may refer to these assessment tools as one of the investigations that was performed during the assessment process. may be used to help generate these. Clinical Impressions may refer to these assessment tools as one of the investigations that was performed during the assessment process.

4.6.3 Background and Context 4.8.3 Background and Context An important background to understanding this resource is the FHIR wiki page for clinical assessment

An important background to understanding this resource is the FHIR wiki page for clinical assessment . In particular, the storyboards there drove the design of the resource, and will be the basis for all examples created. This resource is referenced by . In particular, the storyboards there drove the design of the resource, and will be the basis for all examples created.

This resource is referenced by condition

4.6.4 Resource Content 4.8.4 Resource Content

Structure

Name Flags Card. Type Description & Constraints Description & Constraints doco
. . ClinicalImpression DomainResource A clinical assessment performed when planning treatments and management strategies for a patient A clinical assessment performed when planning treatments and management strategies for a patient
. . . patient Σ 1..1 Reference ( Patient ) The patient being assessed The patient being assessed
. . . assessor Σ 0..1 Reference ( Practitioner ) The clinician performing the assessment The clinician performing the assessment
. . . status ?! ?! Σ 1..1 code in-progress | completed | entered-in-error in-progress | completed | entered-in-error
ClinicalImpressionStatus ( ( Required )
. . . date Σ 0..1 dateTime When the assessment occurred When the assessment occurred
. . . description Σ 0..1 string Why/how the assessment was performed Why/how the assessment was performed
. . . previous 0..1 Reference ( ClinicalImpression ) Reference to last assessment Reference to last assessment
. . . problem Σ 0..* Reference ( Condition | | AllergyIntolerance ) General assessment of patient state General assessment of patient state
. . . trigger[x] 0..1 Request or event that necessitated this assessment Request or event that necessitated this assessment
SNOMED CT Clinical Findings ( SNOMED CT Clinical Findings ( Example )
. . . . triggerCodeableConcept CodeableConcept
. . . triggerReference . triggerReference Reference ( Any )
. . . investigations 0..* BackboneElement One or more sets of investigations (signs, symptions, etc.) One or more sets of investigations (signs, symptions, etc.)
. . . . code 1..1 CodeableConcept A name/code for the set A name/code for the set
Condition/Diagnosis Certainty ( Investigation Type ( Example )
. . . . item 0..* Reference ( Observation | | QuestionnaireResponse | | FamilyMemberHistory | | DiagnosticReport ) Record of a specific investigation Record of a specific investigation
. . . protocol 0..1 uri Clinical Protocol followed Clinical Protocol followed
. . . summary 0..1 string Summary of the assessment Summary of the assessment
. . . finding 0..* BackboneElement Possible or likely findings and diagnoses Possible or likely findings and diagnoses
. . . . item 1..1 CodeableConcept Specific text or code for finding Specific text or code for finding
Condition/Problem/Diagnosis Codes ( Condition/Problem/Diagnosis Codes ( Example )
. . . . cause 0..1 string Which investigations support finding Which investigations support finding
. . . resolved 0..* CodeableConcept Diagnoses/conditions resolved since previous assessment Diagnoses/conditions resolved since previous assessment
Condition/Problem/Diagnosis Codes ( Condition/Problem/Diagnosis Codes ( Example )
. . . ruledOut 0..* BackboneElement Diagnosis considered not possible Diagnosis considered not possible
. . . . item 1..1 CodeableConcept Specific text of code for diagnosis Specific text of code for diagnosis
Condition/Problem/Diagnosis Codes ( Condition/Problem/Diagnosis Codes ( Example )
. . . . reason 0..1 string Grounds for elimination Grounds for elimination
. . . prognosis 0..1 string Estimate of likely outcome Estimate of likely outcome
. . . plan 0..* Reference ( CarePlan | | Appointment | | CommunicationRequest | | DeviceUseRequest | | DiagnosticOrder | | MedicationOrder | | NutritionOrder | | Order | | ProcedureRequest | | ProcessRequest | | ReferralRequest | | SupplyRequest | | VisionPrescription ) Plan of action after assessment Plan of action after assessment
. . . action 0..* Reference ( ReferralRequest | | ProcedureRequest | | Procedure | | MedicationOrder | | DiagnosticOrder | | NutritionOrder | | SupplyRequest | | Appointment ) Actions taken during assessment Actions taken during assessment

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

ClinicalImpression ( ( DomainResource ) The patient being assessed The patient being assessed patient : : Reference [1..1] « [1..1] « Patient » » The clinician performing the assessment The clinician performing the assessment assessor : : Reference [0..1] « [0..1] « Practitioner » » Identifies the workflow status of the assessment (this element modifies the meaning of other elements) Identifies the workflow status of the assessment (this element modifies the meaning of other elements) status : : code [1..1] « [1..1] « The workflow state of a clinical impression. (Strength=Required) The workflow state of a clinical impression. (Strength=Required) ClinicalImpressionStatus ! » ! » The point in time at which the assessment was concluded (not when it was recorded) The point in time at which the assessment was concluded (not when it was recorded) date : : dateTime [0..1] [0..1] A summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/sstatus prompted it A summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/sstatus prompted it description : : string [0..1] [0..1] 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 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 previous : : Reference [0..1] « [0..1] « ClinicalImpression » » This a list of the general problems/conditions for a patient This a list of the general problems/conditions for a patient problem : : Reference [0..*] « [0..*] « Condition | AllergyIntolerance » » The request or event that necessitated this assessment. This may be a diagnosis, a Care Plan, a Request Referral, or some other resource The request or event that necessitated this assessment. This may be a diagnosis, a Care Plan, a Request Referral, or some other resource trigger[x] : : Type [0..1] « [0..1] « CodeableConcept | Reference ( Any ); ); Clinical Findings that may cause an clinical evaluation. (Strength=Example) Clinical Findings that may cause an clinical evaluation. (Strength=Example) SNOMED CT SNOMED CT Clinical Findings Clinical Findings ?? » ?? » Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis protocol : : uri [0..1] [0..1] A text summary of the investigations and the diagnosis A text summary of the investigations and the diagnosis summary : : string [0..1] [0..1] Diagnoses/conditions resolved since the last assessment Diagnoses/conditions resolved since the last assessment resolved : : CodeableConcept [0..*] « [0..*] « Identification of the Condition or diagnosis. (Strength=Example) Identification of the Condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis ?? » Condition/Problem/Diagnosis ?? » Estimate of likely outcome Estimate of likely outcome prognosis : : string [0..1] [0..1] Plan of action after assessment Plan of action after assessment plan : : Reference [0..*] « [0..*] « CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription » » Actions taken during assessment Actions taken during assessment action : : Reference [0..*] « [0..*] « ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticOrder | NutritionOrder | SupplyRequest | Appointment » » Investigations 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 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 code : : CodeableConcept [1..1] « [1..1] « A name/code for a set of investigations. (Strength=Example) A name/code for a set of investigations. (Strength=Example) Condition/Diagnosis Certainty Investigation Type ?? » ?? » A record of a specific investigation that was undertaken A record of a specific investigation that was undertaken item : : Reference [0..*] « [0..*] « Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport » » Finding Specific text of code for finding or diagnosis Specific text of code for finding or diagnosis item : : CodeableConcept [1..1] « [1..1] « Identification of the Condition or diagnosis. (Strength=Example) Identification of the Condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis ?? » Condition/Problem/Diagnosis ?? » Which investigations support finding or diagnosis Which investigations support finding or diagnosis cause : : string [0..1] [0..1] RuledOut Specific text of code for diagnosis Specific text of code for diagnosis item : : CodeableConcept [1..1] « [1..1] « Identification of the Condition or diagnosis. (Strength=Example) Identification of the Condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis ?? » Condition/Problem/Diagnosis ?? » Grounds for elimination Grounds for elimination reason : : string [0..1] [0..1] 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 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 investigations [0..*] Specific findings or diagnoses that was considered likely or relevant to ongoing treatment Specific findings or diagnoses that was considered likely or relevant to ongoing treatment finding [0..*] Diagnosis considered not possible Diagnosis considered not possible ruledOut [0..*]

XML Template XML Template 

<ClinicalImpression xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <patient><!-- 1..1 Reference(Patient) The patient being assessed --></patient>
 <assessor><!-- 0..1 Reference(Practitioner) The clinician performing the assessment --></assessor>
 <status value="[code]"/><!-- 1..1 in-progress | completed | entered-in-error -->
 <date value="[dateTime]"/><!-- 0..1 When the assessment occurred -->
 <description value="[string]"/><!-- 0..1 Why/how the assessment was performed -->
 <previous><!-- 0..1 Reference(ClinicalImpression) Reference to last assessment --></previous>
 <problem><!-- 0..* Reference(Condition|AllergyIntolerance) General assessment of patient state --></problem>
 <trigger[x]><!-- 0..1 CodeableConcept|Reference(Any) Request or event that necessitated this assessment --></trigger[x]>
 <investigations>  <!-- 0..* One or more sets of investigations (signs, symptions, etc.) -->
  <code><!-- 1..1 CodeableConcept A name/code for the set --></code>
  <item><!-- 0..* Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|
    DiagnosticReport) Record of a specific investigation --></item>
 </investigations>
 <protocol value="[uri]"/><!-- 0..1 Clinical Protocol followed -->
 <summary value="[string]"/><!-- 0..1 Summary of the assessment -->
 <finding>  <!-- 0..* Possible or likely findings and diagnoses -->
  <item><!-- 1..1 CodeableConcept Specific text or code for finding --></item>
  <cause value="[string]"/><!-- 0..1 Which investigations support finding -->
 </finding>
 <resolved><!-- 0..* CodeableConcept Diagnoses/conditions resolved since previous assessment --></resolved>
 <ruledOut>  <!-- 0..* Diagnosis considered not possible -->
  <item><!-- 1..1 CodeableConcept Specific text of code for diagnosis --></item>
  <reason value="[string]"/><!-- 0..1 Grounds for elimination -->
 </ruledOut>
 <prognosis value="[string]"/><!-- 0..1 Estimate of likely outcome -->
 <plan><!-- 0..* Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) Plan of action after assessment --></plan>
 <action><!-- 0..* Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticOrder|NutritionOrder|SupplyRequest|Appointment) Actions taken during assessment --></action>
</ClinicalImpression>

JSON Template JSON Template 

{doco
  "resourceType" : "ClinicalImpression",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "patient" : { Reference(Patient) }, // R!  The patient being assessed
  "assessor" : { Reference(Practitioner) }, // The clinician performing the assessment
  "status" : "<code>", // R!  in-progress | completed | entered-in-error
  "date" : "<dateTime>", // When the assessment occurred
  "description" : "<string>", // Why/how the assessment was performed
  "previous" : { Reference(ClinicalImpression) }, // Reference to last assessment
  "problem" : [{ Reference(Condition|AllergyIntolerance) }], // General assessment of patient state
  // trigger[x]: Request or event that necessitated this assessment. One of these 2:
  "triggerCodeableConcept" : { CodeableConcept },
  "triggerReference" : { Reference(Any) },
  "investigations" : [{ // One or more sets of investigations (signs, symptions, etc.)
    "code" : { CodeableConcept }, // R!  A name/code for the set
    "item" : [{ Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|
    DiagnosticReport) }] // Record of a specific investigation
  }],
  "protocol" : "<uri>", // Clinical Protocol followed
  "summary" : "<string>", // Summary of the assessment
  "finding" : [{ // Possible or likely findings and diagnoses
    "item" : { CodeableConcept }, // R!  Specific text or code for finding
    "cause" : "<string>" // Which investigations support finding
  }],
  "resolved" : [{ CodeableConcept }], // Diagnoses/conditions resolved since previous assessment
  "ruledOut" : [{ // Diagnosis considered not possible
    "item" : { CodeableConcept }, // R!  Specific text of code for diagnosis
    "reason" : "<string>" // Grounds for elimination
  }],
  "prognosis" : "<string>", // Estimate of likely outcome
  "plan" : [{ Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) }], // Plan of action after assessment
  "action" : [{ Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticOrder|NutritionOrder|SupplyRequest|Appointment) }] // Actions taken during assessment
}

Structure

Name Flags Card. Type Description & Constraints Description & Constraints doco
. . ClinicalImpression DomainResource A clinical assessment performed when planning treatments and management strategies for a patient A clinical assessment performed when planning treatments and management strategies for a patient
. . . patient Σ 1..1 Reference ( Patient ) The patient being assessed The patient being assessed
. . . assessor Σ 0..1 Reference ( Practitioner ) The clinician performing the assessment The clinician performing the assessment
. . . status ?! ?! Σ 1..1 code in-progress | completed | entered-in-error in-progress | completed | entered-in-error
ClinicalImpressionStatus ( ( Required )
. . . date Σ 0..1 dateTime When the assessment occurred When the assessment occurred
. . . description Σ 0..1 string Why/how the assessment was performed Why/how the assessment was performed
. . . previous 0..1 Reference ( ClinicalImpression ) Reference to last assessment Reference to last assessment
. . . problem Σ 0..* Reference ( Condition | | AllergyIntolerance ) General assessment of patient state General assessment of patient state
. . . trigger[x] 0..1 Request or event that necessitated this assessment Request or event that necessitated this assessment
SNOMED CT Clinical Findings ( SNOMED CT Clinical Findings ( Example )
. . . . triggerCodeableConcept CodeableConcept
. . . triggerReference . triggerReference Reference ( Any )
. . . investigations 0..* BackboneElement One or more sets of investigations (signs, symptions, etc.) One or more sets of investigations (signs, symptions, etc.)
. . . . code 1..1 CodeableConcept A name/code for the set A name/code for the set
Condition/Diagnosis Certainty ( Investigation Type ( Example )
. . . . item 0..* Reference ( Observation | | QuestionnaireResponse | | FamilyMemberHistory | | DiagnosticReport ) Record of a specific investigation Record of a specific investigation
. . . protocol 0..1 uri Clinical Protocol followed Clinical Protocol followed
. . . summary 0..1 string Summary of the assessment Summary of the assessment
. . . finding 0..* BackboneElement Possible or likely findings and diagnoses Possible or likely findings and diagnoses
. . . . item 1..1 CodeableConcept Specific text or code for finding Specific text or code for finding
Condition/Problem/Diagnosis Codes ( Condition/Problem/Diagnosis Codes ( Example )
. . . . cause 0..1 string Which investigations support finding Which investigations support finding
. . . resolved 0..* CodeableConcept Diagnoses/conditions resolved since previous assessment Diagnoses/conditions resolved since previous assessment
Condition/Problem/Diagnosis Codes ( Condition/Problem/Diagnosis Codes ( Example )
. . . ruledOut 0..* BackboneElement Diagnosis considered not possible Diagnosis considered not possible
. . . . item 1..1 CodeableConcept Specific text of code for diagnosis Specific text of code for diagnosis
Condition/Problem/Diagnosis Codes ( Condition/Problem/Diagnosis Codes ( Example )
. . . . reason 0..1 string Grounds for elimination Grounds for elimination
. . . prognosis 0..1 string Estimate of likely outcome Estimate of likely outcome
. . . plan 0..* Reference ( CarePlan | | Appointment | | CommunicationRequest | | DeviceUseRequest | | DiagnosticOrder | | MedicationOrder | | NutritionOrder | | Order | | ProcedureRequest | | ProcessRequest | | ReferralRequest | | SupplyRequest | | VisionPrescription ) Plan of action after assessment Plan of action after assessment
. . . action 0..* Reference ( ReferralRequest | | ProcedureRequest | | Procedure | | MedicationOrder | | DiagnosticOrder | | NutritionOrder | | SupplyRequest | | Appointment ) Actions taken during assessment Actions taken during assessment

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram

ClinicalImpression ( ( DomainResource ) The patient being assessed The patient being assessed patient : : Reference [1..1] « [1..1] « Patient » » The clinician performing the assessment The clinician performing the assessment assessor : : Reference [0..1] « [0..1] « Practitioner » » Identifies the workflow status of the assessment (this element modifies the meaning of other elements) Identifies the workflow status of the assessment (this element modifies the meaning of other elements) status : : code [1..1] « [1..1] « The workflow state of a clinical impression. (Strength=Required) The workflow state of a clinical impression. (Strength=Required) ClinicalImpressionStatus ! » ! » The point in time at which the assessment was concluded (not when it was recorded) The point in time at which the assessment was concluded (not when it was recorded) date : : dateTime [0..1] [0..1] A summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/sstatus prompted it A summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/sstatus prompted it description : : string [0..1] [0..1] 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 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 previous : : Reference [0..1] « [0..1] « ClinicalImpression » » This a list of the general problems/conditions for a patient This a list of the general problems/conditions for a patient problem : : Reference [0..*] « [0..*] « Condition | AllergyIntolerance » » The request or event that necessitated this assessment. This may be a diagnosis, a Care Plan, a Request Referral, or some other resource The request or event that necessitated this assessment. This may be a diagnosis, a Care Plan, a Request Referral, or some other resource trigger[x] : : Type [0..1] « [0..1] « CodeableConcept | Reference ( Any ); ); Clinical Findings that may cause an clinical evaluation. (Strength=Example) Clinical Findings that may cause an clinical evaluation. (Strength=Example) SNOMED CT SNOMED CT Clinical Findings Clinical Findings ?? » ?? » Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis protocol : : uri [0..1] [0..1] A text summary of the investigations and the diagnosis A text summary of the investigations and the diagnosis summary : : string [0..1] [0..1] Diagnoses/conditions resolved since the last assessment Diagnoses/conditions resolved since the last assessment resolved : : CodeableConcept [0..*] « [0..*] « Identification of the Condition or diagnosis. (Strength=Example) Identification of the Condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis ?? » Condition/Problem/Diagnosis ?? » Estimate of likely outcome Estimate of likely outcome prognosis : : string [0..1] [0..1] Plan of action after assessment Plan of action after assessment plan : : Reference [0..*] « [0..*] « CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription » » Actions taken during assessment Actions taken during assessment action : : Reference [0..*] « [0..*] « ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticOrder | NutritionOrder | SupplyRequest | Appointment » » Investigations 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 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 code : : CodeableConcept [1..1] « [1..1] « A name/code for a set of investigations. (Strength=Example) A name/code for a set of investigations. (Strength=Example) Condition/Diagnosis Certainty Investigation Type ?? » ?? » A record of a specific investigation that was undertaken A record of a specific investigation that was undertaken item : : Reference [0..*] « [0..*] « Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport » » Finding Specific text of code for finding or diagnosis Specific text of code for finding or diagnosis item : : CodeableConcept [1..1] « [1..1] « Identification of the Condition or diagnosis. (Strength=Example) Identification of the Condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis ?? » Condition/Problem/Diagnosis ?? » Which investigations support finding or diagnosis Which investigations support finding or diagnosis cause : : string [0..1] [0..1] RuledOut Specific text of code for diagnosis Specific text of code for diagnosis item : : CodeableConcept [1..1] « [1..1] « Identification of the Condition or diagnosis. (Strength=Example) Identification of the Condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis ?? » Condition/Problem/Diagnosis ?? » Grounds for elimination Grounds for elimination reason : : string [0..1] [0..1] 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 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 investigations [0..*] Specific findings or diagnoses that was considered likely or relevant to ongoing treatment Specific findings or diagnoses that was considered likely or relevant to ongoing treatment finding [0..*] Diagnosis considered not possible Diagnosis considered not possible ruledOut [0..*]

XML Template XML Template 

<ClinicalImpression xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <patient><!-- 1..1 Reference(Patient) The patient being assessed --></patient>
 <assessor><!-- 0..1 Reference(Practitioner) The clinician performing the assessment --></assessor>
 <status value="[code]"/><!-- 1..1 in-progress | completed | entered-in-error -->
 <date value="[dateTime]"/><!-- 0..1 When the assessment occurred -->
 <description value="[string]"/><!-- 0..1 Why/how the assessment was performed -->
 <previous><!-- 0..1 Reference(ClinicalImpression) Reference to last assessment --></previous>
 <problem><!-- 0..* Reference(Condition|AllergyIntolerance) General assessment of patient state --></problem>
 <trigger[x]><!-- 0..1 CodeableConcept|Reference(Any) Request or event that necessitated this assessment --></trigger[x]>
 <investigations>  <!-- 0..* One or more sets of investigations (signs, symptions, etc.) -->
  <code><!-- 1..1 CodeableConcept A name/code for the set --></code>
  <item><!-- 0..* Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|
    DiagnosticReport) Record of a specific investigation --></item>
 </investigations>
 <protocol value="[uri]"/><!-- 0..1 Clinical Protocol followed -->
 <summary value="[string]"/><!-- 0..1 Summary of the assessment -->
 <finding>  <!-- 0..* Possible or likely findings and diagnoses -->
  <item><!-- 1..1 CodeableConcept Specific text or code for finding --></item>
  <cause value="[string]"/><!-- 0..1 Which investigations support finding -->
 </finding>
 <resolved><!-- 0..* CodeableConcept Diagnoses/conditions resolved since previous assessment --></resolved>
 <ruledOut>  <!-- 0..* Diagnosis considered not possible -->
  <item><!-- 1..1 CodeableConcept Specific text of code for diagnosis --></item>
  <reason value="[string]"/><!-- 0..1 Grounds for elimination -->
 </ruledOut>
 <prognosis value="[string]"/><!-- 0..1 Estimate of likely outcome -->
 <plan><!-- 0..* Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) Plan of action after assessment --></plan>
 <action><!-- 0..* Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticOrder|NutritionOrder|SupplyRequest|Appointment) Actions taken during assessment --></action>
</ClinicalImpression>

JSON Template JSON Template 

{doco
  "resourceType" : "ClinicalImpression",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "patient" : { Reference(Patient) }, // R!  The patient being assessed
  "assessor" : { Reference(Practitioner) }, // The clinician performing the assessment
  "status" : "<code>", // R!  in-progress | completed | entered-in-error
  "date" : "<dateTime>", // When the assessment occurred
  "description" : "<string>", // Why/how the assessment was performed
  "previous" : { Reference(ClinicalImpression) }, // Reference to last assessment
  "problem" : [{ Reference(Condition|AllergyIntolerance) }], // General assessment of patient state
  // trigger[x]: Request or event that necessitated this assessment. One of these 2:
  "triggerCodeableConcept" : { CodeableConcept },
  "triggerReference" : { Reference(Any) },
  "investigations" : [{ // One or more sets of investigations (signs, symptions, etc.)
    "code" : { CodeableConcept }, // R!  A name/code for the set
    "item" : [{ Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|
    DiagnosticReport) }] // Record of a specific investigation
  }],
  "protocol" : "<uri>", // Clinical Protocol followed
  "summary" : "<string>", // Summary of the assessment
  "finding" : [{ // Possible or likely findings and diagnoses
    "item" : { CodeableConcept }, // R!  Specific text or code for finding
    "cause" : "<string>" // Which investigations support finding
  }],
  "resolved" : [{ CodeableConcept }], // Diagnoses/conditions resolved since previous assessment
  "ruledOut" : [{ // Diagnosis considered not possible
    "item" : { CodeableConcept }, // R!  Specific text of code for diagnosis
    "reason" : "<string>" // Grounds for elimination
  }],
  "prognosis" : "<string>", // Estimate of likely outcome
  "plan" : [{ Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticOrder|MedicationOrder|NutritionOrder|Order|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) }], // Plan of action after assessment
  "action" : [{ Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticOrder|NutritionOrder|SupplyRequest|Appointment) }] // Actions taken during assessment
}

  Alternate definitions:

Alternate definitions: Schema / Schematron , Resource Profile ( , Resource Profile ( XML , , JSON ), ), Questionnaire

4.6.4.1 Terminology Bindings 4.8.4.1 Terminology Bindings

ClinicalImpression.investigations.code
Path Definition Type Reference
ClinicalImpression.status ClinicalImpression.status The workflow state of a clinical impression. The workflow state of a clinical impression. Required ClinicalImpressionStatus
ClinicalImpression.trigger[x] ClinicalImpression.trigger[x] Clinical Findings that may cause an clinical evaluation. Clinical Findings that may cause an clinical evaluation. Example SNOMED CT Clinical Findings SNOMED CT Clinical Findings
ClinicalImpression.investigations.code A name/code for a set of investigations. A name/code for a set of investigations. Example Condition/Diagnosis Certainty Investigation Type
ClinicalImpression.finding.item
ClinicalImpression.resolved
ClinicalImpression.ruledOut.item ClinicalImpression.ruledOut.item 		Identification of the Condition or diagnosis. Identification of the Condition or diagnosis. Example Condition/Problem/Diagnosis Codes Condition/Problem/Diagnosis Codes

4.6.5 Search Parameters 4.8.5 Search Parameters Search parameters for this resource. The common parameters also apply. See

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services. for more information about searching in REST, messaging, and services.

© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search
Name Type Description Paths
action reference Actions taken during assessment Actions taken during assessment ClinicalImpression.action
( ReferralRequest , , Appointment , , ProcedureRequest , , SupplyRequest , , Procedure , , MedicationOrder , , NutritionOrder , , DiagnosticOrder )
assessor reference The clinician performing the assessment The clinician performing the assessment ClinicalImpression.assessor
( Practitioner )
date date When the assessment occurred When the assessment occurred ClinicalImpression.date
finding token Specific text or code for finding Specific text or code for finding ClinicalImpression.finding.item
investigation reference Record of a specific investigation Record of a specific investigation ClinicalImpression.investigations.item
( FamilyMemberHistory , , Observation , , QuestionnaireResponse , , DiagnosticReport )
patient reference The patient being assessed The patient being assessed ClinicalImpression.patient
( Patient )
plan reference Plan of action after assessment Plan of action after assessment ClinicalImpression.plan
( CarePlan , , ReferralRequest , , ProcedureRequest , , Appointment , , CommunicationRequest , , Order , , SupplyRequest , , VisionPrescription , , MedicationOrder , , ProcessRequest , , DeviceUseRequest , , NutritionOrder , , DiagnosticOrder )
previous reference Reference to last assessment Reference to last assessment ClinicalImpression.previous
( ClinicalImpression )
problem reference General assessment of patient state General assessment of patient state ClinicalImpression.problem
( Condition , , AllergyIntolerance )
resolved token Diagnoses/conditions resolved since previous assessment Diagnoses/conditions resolved since previous assessment ClinicalImpression.resolved
ruledout token Specific text of code for diagnosis Specific text of code for diagnosis ClinicalImpression.ruledOut.item
status token in-progress | completed | entered-in-error in-progress | completed | entered-in-error ClinicalImpression.status
trigger reference Request or event that necessitated this assessment Request or event that necessitated this assessment ClinicalImpression.triggerReference
(Any)
trigger-code token Request or event that necessitated this assessment Request or event that necessitated this assessment ClinicalImpression.triggerCodeableConcept