DSTU2 STU 3 Ballot
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 (v1.6.0: STU 3 Ballot 4). 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 9.6 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 : : Encounter , 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 9.6.1 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.

An impression is a clinical summation of information and/or an opinion formed, which is the outcome of the clinical assessment process. The ClinicalImpression may lead to a statement of a Condition about a patient.

In FHIR, an assessment is typically an instrument or tool used to collect information about a patient.

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 9.6.2 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 9.6.3 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.

PLANNED CHANGE:

Communication is one of the Event resources in the FHIR Workflow specification. As such, it is expected to be adjusted to align with the Event workflow pattern which will involve adding a number of additional data elements and potentially renaming a few elements. Any concerns about performing such alignment are welcome as ballot comments and/or tracker items.

This resource is referenced by condition

4.6.4 Resource Content 9.6.4 Resource Content

Structure

CodeableConcept Which investigations support finding
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 . identifier Σ 1..1 0..* Reference ( Patient Identifier ) The patient being assessed Business identifier
. . assessor . status ?! Σ 0..1 1..1 Reference ( Practitioner code ) The clinician performing the assessment draft | completed | entered-in-error
ClinicalImpressionStatus ( Required )
. . status . code ?! Σ 1..1 0..1 code CodeableConcept in-progress | completed | entered-in-error ClinicalImpressionStatus ( Required ) Kind of impression performed
. . date . description Σ 0..1 dateTime string When the assessment occurred Why/how the assessment was performed
. . description . subject Σ 0..1 1..1 string Reference ( Patient | Group ) Why/how the assessment was performed Patient or group assessed
. . previous . assessor Σ 0..1 Reference ( ClinicalImpression Practitioner ) Reference to last assessment The clinician performing the assessment
. . problem . date Σ 0..* 0..1 Reference ( Condition | AllergyIntolerance dateTime ) General assessment of patient state When the assessment was documented
. . trigger[x] . effective[x] Σ 0..1 Request or event that necessitated this assessment SNOMED CT Clinical Findings ( Example ) Time of assessment
. . . triggerCodeableConcept . effectiveDateTime CodeableConcept dateTime
. . . . effectivePeriod triggerReference Period
... context Σ 0..1 Reference ( Any Encounter | EpisodeOfCare ) Encounter or Episode created from
... previous 0..1 Reference ( ClinicalImpression ) Reference to last assessment
... problem Σ 0..* Reference ( Condition | AllergyIntolerance ) Relevant impressions of patient state
. . . 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 | RiskAssessment | ImagingStudy ) Record of a specific investigation Record of a specific investigation
. . . protocol 0..1 0..* 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 . item[x] 1..1 Specific text or code for finding What was found
Condition/Problem/Diagnosis Codes ( Condition/Problem/Diagnosis Codes ( Example )
. . . cause . . itemCodeableConcept 0..1 string CodeableConcept
. . resolved . . . itemReference 0..* CodeableConcept Diagnoses/conditions resolved since previous assessment Condition/Problem/Diagnosis Codes Reference ( Example Condition | Observation )
. ruledOut . . . cause 0..* 0..1 BackboneElement string Diagnosis considered not possible Which investigations support finding
. . item . prognosisCodeableConcept 1..1 0..* CodeableConcept Specific text of code for diagnosis Estimate of likely outcome
Condition/Problem/Diagnosis Codes ( Clinical Impression Prognosis ( Example )
. . reason . prognosisReference 0..1 0..* string Reference ( RiskAssessment ) Grounds for elimination RiskAssessment expressing likely outcome
. . prognosis . plan 0..1 0..* string Reference ( CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticRequest | MedicationOrder | NutritionRequest | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription ) Estimate of likely outcome Plan of action after assessment
. . plan . action 0..* Reference ( CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | | ProcedureRequest | Procedure | MedicationOrder | DiagnosticRequest | NutritionRequest | SupplyRequest | VisionPrescription | Appointment ) Plan of action after assessment Actions taken during assessment
. . action . note 0..* Reference ( ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticOrder | NutritionOrder | SupplyRequest | Appointment Annotation ) Actions taken during assessment Comments made about the ClinicalImpression

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram ( Legend )

ClinicalImpression ( ( DomainResource ) The patient being assessed patient : Reference [1..1] « Patient » The clinician performing the assessment A unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored on assessor : Reference [0..1] « Practitioner » identifier : Identifier [0..*] 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) Categorizes the type of clinical impression performed date : dateTime [0..1] code : CodeableConcept [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/status 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 The patient or group of individuals assessed as part of this record previous : subject : Reference [1..1] « Patient [0..1] « ClinicalImpression » | Group » This a list of the general problems/conditions for a patient The clinician performing the assessment problem : assessor : Reference [0..*] « Condition | AllergyIntolerance » [0..1] « Practitioner » The request or event that necessitated this assessment. This may be a diagnosis, a Care Plan, a Request Referral, or some other resource Indicates when the documentation of the assessment was complete trigger[x] : date : dateTime [0..1] The point in time or period over which the subject was assessed effective[x] : Type [0..1] « CodeableConcept [0..1] « dateTime | Reference ( Any ); Period » Clinical Findings that may cause an clinical evaluation. (Strength=Example) The encounter or episode of care this impression was created as part of SNOMED CT context : Reference [0..1] « Encounter | EpisodeOfCare » 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] « ClinicalImpression » Clinical Findings This a list of the relevant problems/conditions for a patient problem : Reference [0..*] « Condition ?? » | AllergyIntolerance » 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..*] 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 Estimate of likely outcome resolved : prognosisCodeableConcept : CodeableConcept [0..*] « [0..*] « Identification of the Condition or diagnosis. (Strength=Example) Prognosis or outlook findings (Strength=Example) Condition/Problem/Diagnosis Clinical ?? » Impression Prognosis ?? » Estimate of likely outcome RiskAssessment expressing likely outcome prognosis : string [0..1] prognosisReference : Reference [0..*] « RiskAssessment » Plan of action after assessment Plan of action after assessment plan : : Reference [0..*] « [0..*] « CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder DiagnosticRequest | MedicationOrder | NutritionOrder | Order NutritionRequest | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription » » Actions taken during assessment Actions taken during assessment action : : Reference [0..*] « [0..*] « ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticOrder DiagnosticRequest | NutritionOrder NutritionRequest | SupplyRequest | Appointment » » Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear note : Annotation [0..*] 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 » | RiskAssessment | ImagingStudy » Finding Specific text of code for finding or diagnosis Specific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditions item : item[x] : Type [1..1] « CodeableConcept [1..1] « Identification of the Condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis ?? » Which investigations support finding or diagnosis cause | Reference : string ( Condition [0..1] RuledOut | Specific text of code for diagnosis item : CodeableConcept Observation [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 Which investigations support finding or diagnosis reason : cause : 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 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>
 <</assessor>
 <
 <
 <
 <</previous>
 <</problem>
 <</trigger[x]>
 <
  <</code>
  <|
    </item>

 <identifier><!-- 0..* Identifier Business identifier --></identifier>
 <status value="[code]"/><!-- 1..1 draft | completed | entered-in-error -->
 <code><!-- 0..1 CodeableConcept Kind of impression performed --></code>
 <description value="[string]"/><!-- 0..1 Why/how the assessment was performed -->
 <subject><!-- 1..1 Reference(Patient|Group) Patient or group assessed --></subject>
 <assessor><!-- 0..1 Reference(Practitioner) The clinician performing the assessment --></assessor>
 <date value="[dateTime]"/><!-- 0..1 When the assessment was documented -->
 <effective[x]><!-- 0..1 dateTime|Period Time of assessment --></effective[x]>
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Encounter or Episode created from --></context>
 <previous><!-- 0..1 Reference(ClinicalImpression) Reference to last assessment --></previous>
 <problem><!-- 0..* Reference(Condition|AllergyIntolerance) Relevant impressions of patient state --></problem>
 <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|RiskAssessment|ImagingStudy) Record of a specific investigation --></item>
 </investigations>
 <
 <
 <
  <</item>
  <

 <protocol value="[uri]"/><!-- 0..* Clinical Protocol followed -->
 <summary value="[string]"/><!-- 0..1 Summary of the assessment -->
 <finding>  <!-- 0..* Possible or likely findings and diagnoses -->
  <item[x]><!-- 1..1 CodeableConcept|Reference(Condition|Observation) What was found --></item[x]>
  <cause value="[string]"/><!-- 0..1 Which investigations support finding -->

 </finding>
 <</resolved>
 <
  <</item>
  <
 </ruledOut>
 <
 <|
   |

 <prognosisCodeableConcept><!-- 0..* CodeableConcept Estimate of likely outcome --></prognosisCodeableConcept>
 <prognosisReference><!-- 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome --></prognosisReference>
 <plan><!-- 0..* Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticRequest|MedicationOrder|NutritionRequest|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) Plan of action after assessment --></plan>
 <|
   </action>

 <action><!-- 0..* Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticRequest|NutritionRequest|SupplyRequest|Appointment) Actions taken during assessment --></action>

 <note><!-- 0..* Annotation Comments made about the ClinicalImpression --></note>

</ClinicalImpression>

JSON Template JSON Template { "resourceType" : "", 

{doco
  "resourceType" : "ClinicalImpression",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  
  " },
  " },
  "
    "
    "|
    
  }],
  "
  "
  "
    "
    "

  "identifier" : [{ Identifier }], // Business identifier
  "status" : "<code>", // R!  draft | completed | entered-in-error
  "code" : { CodeableConcept }, // Kind of impression performed
  "description" : "<string>", // Why/how the assessment was performed
  "subject" : { Reference(Patient|Group) }, // R!  Patient or group assessed
  "assessor" : { Reference(Practitioner) }, // The clinician performing the assessment
  "date" : "<dateTime>", // When the assessment was documented
  // effective[x]: Time of assessment. One of these 2:

  "effectiveDateTime" : "<dateTime>",
  "effectivePeriod" : { Period },
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Encounter or Episode created from
  "previous" : { Reference(ClinicalImpression) }, // Reference to last assessment
  "problem" : [{ Reference(Condition|AllergyIntolerance) }], // Relevant impressions of patient state
  "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|RiskAssessment|ImagingStudy) }] // Record of a specific investigation
  }],
  "
  "
    "
    "

  "protocol" : ["<uri>"], // Clinical Protocol followed
  "summary" : "<string>", // Summary of the assessment
  "finding" : [{ // Possible or likely findings and diagnoses
    // item[x]: What was found. One of these 2:

    "itemCodeableConcept" : { CodeableConcept },
    "itemReference" : { Reference(Condition|Observation) },
    "cause" : "<string>" // Which investigations support finding

  }],
  "
  "|
   |

  "prognosisCodeableConcept" : [{ CodeableConcept }], // Estimate of likely outcome
  "prognosisReference" : [{ Reference(RiskAssessment) }], // RiskAssessment expressing likely outcome
  "plan" : [{ Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticRequest|MedicationOrder|NutritionRequest|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) }], // Plan of action after assessment
  "|
   

  "action" : [{ Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticRequest|NutritionRequest|SupplyRequest|Appointment) }], // Actions taken during assessment

  "note" : [{ Annotation }] // Comments made about the ClinicalImpression

}

Turtle Template 


@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClinicalImpression;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClinicalImpression.identifier [ Identifier ], ... ; # 0..* Business identifier
  fhir:ClinicalImpression.status [ code ]; # 1..1 draft | completed | entered-in-error
  fhir:ClinicalImpression.code [ CodeableConcept ]; # 0..1 Kind of impression performed
  fhir:ClinicalImpression.description [ string ]; # 0..1 Why/how the assessment was performed
  fhir:ClinicalImpression.subject [ Reference(Patient|Group) ]; # 1..1 Patient or group assessed
  fhir:ClinicalImpression.assessor [ Reference(Practitioner) ]; # 0..1 The clinician performing the assessment
  fhir:ClinicalImpression.date [ dateTime ]; # 0..1 When the assessment was documented
  # ClinicalImpression.effective[x] : 0..1 Time of assessment. One of these 2
    fhir:ClinicalImpression.effectiveDateTime [ dateTime ]
    fhir:ClinicalImpression.effectivePeriod [ Period ]
  fhir:ClinicalImpression.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Encounter or Episode created from
  fhir:ClinicalImpression.previous [ Reference(ClinicalImpression) ]; # 0..1 Reference to last assessment
  fhir:ClinicalImpression.problem [ Reference(Condition|AllergyIntolerance) ], ... ; # 0..* Relevant impressions of patient state
  fhir:ClinicalImpression.investigations [ # 0..* One or more sets of investigations (signs, symptions, etc.)
    fhir:ClinicalImpression.investigations.code [ CodeableConcept ]; # 1..1 A name/code for the set
    fhir:ClinicalImpression.investigations.item [ Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|DiagnosticReport|
  RiskAssessment|ImagingStudy) ], ... ; # 0..* Record of a specific investigation

  ], ...;
  fhir:ClinicalImpression.protocol [ uri ], ... ; # 0..* Clinical Protocol followed
  fhir:ClinicalImpression.summary [ string ]; # 0..1 Summary of the assessment
  fhir:ClinicalImpression.finding [ # 0..* Possible or likely findings and diagnoses
    # ClinicalImpression.finding.item[x] : 1..1 What was found. One of these 2
      fhir:ClinicalImpression.finding.itemCodeableConcept [ CodeableConcept ]
      fhir:ClinicalImpression.finding.itemReference [ Reference(Condition|Observation) ]
    fhir:ClinicalImpression.finding.cause [ string ]; # 0..1 Which investigations support finding
  ], ...;
  fhir:ClinicalImpression.prognosisCodeableConcept [ CodeableConcept ], ... ; # 0..* Estimate of likely outcome
  fhir:ClinicalImpression.prognosisReference [ Reference(RiskAssessment) ], ... ; # 0..* RiskAssessment expressing likely outcome
  fhir:ClinicalImpression.plan [ Reference(CarePlan|Appointment|CommunicationRequest|DeviceUseRequest|DiagnosticRequest|
  MedicationOrder|NutritionRequest|ProcedureRequest|ProcessRequest|
  ReferralRequest|SupplyRequest|VisionPrescription) ], ... ; # 0..* Plan of action after assessment

  fhir:ClinicalImpression.action [ Reference(ReferralRequest|ProcedureRequest|Procedure|MedicationOrder|DiagnosticRequest|
  NutritionRequest|SupplyRequest|Appointment) ], ... ; # 0..* Actions taken during assessment

  fhir:ClinicalImpression.note [ Annotation ], ... ; # 0..* Comments made about the ClinicalImpression
]

Changes since DSTU2

ClinicalImpression
ClinicalImpression.identifier added
ClinicalImpression.code added
ClinicalImpression.subject Renamed from patient to subject
Add Reference(Group)
ClinicalImpression.effective[x] added
ClinicalImpression.context added
ClinicalImpression.investigations.item Add Reference(RiskAssessment), Add Reference(ImagingStudy)
ClinicalImpression.protocol Max Cardinality changed from 1 to *
ClinicalImpression.finding.item[x] Renamed from item to item[x]
Add Reference(Condition), Add Reference(Observation)
ClinicalImpression.prognosisCodeableConcept added
ClinicalImpression.prognosisReference added
ClinicalImpression.plan Remove Reference(DiagnosticOrder), Remove Reference(NutritionOrder), Remove Reference(Order), Add Reference(DiagnosticRequest), Add Reference(NutritionRequest)
ClinicalImpression.action Remove Reference(DiagnosticOrder), Remove Reference(NutritionOrder), Add Reference(DiagnosticRequest), Add Reference(NutritionRequest)
ClinicalImpression.note added
ClinicalImpression.trigger[x] deleted
ClinicalImpression.resolved deleted
ClinicalImpression.ruledOut deleted
ClinicalImpression.prognosis deleted

See the Full Difference for further information

Structure

CodeableConcept Which investigations support finding
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 . identifier Σ 1..1 0..* Reference ( Patient Identifier ) The patient being assessed Business identifier
. . assessor . status ?! Σ 0..1 1..1 Reference ( Practitioner code ) The clinician performing the assessment draft | completed | entered-in-error
ClinicalImpressionStatus ( Required )
. . status . code ?! Σ 1..1 0..1 code CodeableConcept in-progress | completed | entered-in-error ClinicalImpressionStatus ( Required ) Kind of impression performed
. . date . description Σ 0..1 dateTime string When the assessment occurred Why/how the assessment was performed
. . description . subject Σ 0..1 1..1 string Reference ( Patient | Group ) Why/how the assessment was performed Patient or group assessed
. . previous . assessor Σ 0..1 Reference ( ClinicalImpression Practitioner ) Reference to last assessment The clinician performing the assessment
. . problem . date Σ 0..* 0..1 Reference ( Condition | AllergyIntolerance dateTime ) General assessment of patient state When the assessment was documented
. . trigger[x] . effective[x] Σ 0..1 Request or event that necessitated this assessment SNOMED CT Clinical Findings ( Example ) Time of assessment
. . . triggerCodeableConcept . effectiveDateTime CodeableConcept dateTime
. . . . effectivePeriod triggerReference Period
... context Σ 0..1 Reference ( Any Encounter | EpisodeOfCare ) Encounter or Episode created from
... previous 0..1 Reference ( ClinicalImpression ) Reference to last assessment
... problem Σ 0..* Reference ( Condition | AllergyIntolerance ) Relevant impressions of patient state
. . . 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 | RiskAssessment | ImagingStudy ) Record of a specific investigation Record of a specific investigation
. . . protocol 0..1 0..* 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 . item[x] 1..1 Specific text or code for finding What was found
Condition/Problem/Diagnosis Codes ( Condition/Problem/Diagnosis Codes ( Example )
. . . cause . . itemCodeableConcept 0..1 string CodeableConcept
. . resolved . . . itemReference 0..* CodeableConcept Diagnoses/conditions resolved since previous assessment Condition/Problem/Diagnosis Codes Reference ( Example Condition | Observation )
. ruledOut . . . cause 0..* 0..1 BackboneElement string Diagnosis considered not possible Which investigations support finding
. . item . prognosisCodeableConcept 1..1 0..* CodeableConcept Specific text of code for diagnosis Estimate of likely outcome
Condition/Problem/Diagnosis Codes ( Clinical Impression Prognosis ( Example )
. . reason . prognosisReference 0..1 0..* string Reference ( RiskAssessment ) Grounds for elimination RiskAssessment expressing likely outcome
. . prognosis . plan 0..1 0..* string Reference ( CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticRequest | MedicationOrder | NutritionRequest | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription ) Estimate of likely outcome Plan of action after assessment
. . plan . action 0..* Reference ( CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | | ProcedureRequest | Procedure | MedicationOrder | DiagnosticRequest | NutritionRequest | SupplyRequest | VisionPrescription | Appointment ) Plan of action after assessment Actions taken during assessment
. . action . note 0..* Reference ( ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticOrder | NutritionOrder | SupplyRequest | Appointment Annotation ) Actions taken during assessment Comments made about the ClinicalImpression

Documentation for this format doco Documentation for this format

UML Diagram UML Diagram ( Legend )

ClinicalImpression ( ( DomainResource ) The patient being assessed patient : Reference [1..1] « Patient » The clinician performing the assessment A unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored on assessor : Reference [0..1] « Practitioner » identifier : Identifier [0..*] 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) Categorizes the type of clinical impression performed date : dateTime [0..1] code : CodeableConcept [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/status 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 The patient or group of individuals assessed as part of this record previous : subject : Reference [1..1] « Patient [0..1] « ClinicalImpression » | Group » This a list of the general problems/conditions for a patient The clinician performing the assessment problem : assessor : Reference [0..*] « Condition | AllergyIntolerance » [0..1] « Practitioner » The request or event that necessitated this assessment. This may be a diagnosis, a Care Plan, a Request Referral, or some other resource Indicates when the documentation of the assessment was complete trigger[x] : date : dateTime [0..1] The point in time or period over which the subject was assessed effective[x] : Type [0..1] « CodeableConcept [0..1] « dateTime | Reference ( Any ); Period » Clinical Findings that may cause an clinical evaluation. (Strength=Example) The encounter or episode of care this impression was created as part of SNOMED CT context : Reference [0..1] « Encounter | EpisodeOfCare » 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] « ClinicalImpression » Clinical Findings This a list of the relevant problems/conditions for a patient problem : Reference [0..*] « Condition ?? » | AllergyIntolerance » 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..*] 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 Estimate of likely outcome resolved : prognosisCodeableConcept : CodeableConcept [0..*] « [0..*] « Identification of the Condition or diagnosis. (Strength=Example) Prognosis or outlook findings (Strength=Example) Condition/Problem/Diagnosis Clinical ?? » Impression Prognosis ?? » Estimate of likely outcome RiskAssessment expressing likely outcome prognosis : string [0..1] prognosisReference : Reference [0..*] « RiskAssessment » Plan of action after assessment Plan of action after assessment plan : : Reference [0..*] « [0..*] « CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder DiagnosticRequest | MedicationOrder | NutritionOrder | Order NutritionRequest | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription » » Actions taken during assessment Actions taken during assessment action : : Reference [0..*] « [0..*] « ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticOrder DiagnosticRequest | NutritionOrder NutritionRequest | SupplyRequest | Appointment » » Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear note : Annotation [0..*] 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 » | RiskAssessment | ImagingStudy » Finding Specific text of code for finding or diagnosis Specific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditions item : item[x] : Type [1..1] « CodeableConcept [1..1] « Identification of the Condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis ?? » Which investigations support finding or diagnosis cause | Reference : string ( Condition [0..1] RuledOut | Specific text of code for diagnosis item : CodeableConcept Observation [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 Which investigations support finding or diagnosis reason : cause : 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 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>
 <</assessor>
 <
 <
 <
 <</previous>
 <</problem>
 <</trigger[x]>
 <
  <</code>
  <|
    </item>

 <identifier><!-- 0..* Identifier Business identifier --></identifier>
 <status value="[code]"/><!-- 1..1 draft | completed | entered-in-error -->
 <code><!-- 0..1 CodeableConcept Kind of impression performed --></code>
 <description value="[string]"/><!-- 0..1 Why/how the assessment was performed -->
 <subject><!-- 1..1 Reference(Patient|Group) Patient or group assessed --></subject>
 <assessor><!-- 0..1 Reference(Practitioner) The clinician performing the assessment --></assessor>
 <date value="[dateTime]"/><!-- 0..1 When the assessment was documented -->
 <effective[x]><!-- 0..1 dateTime|Period Time of assessment --></effective[x]>
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Encounter or Episode created from --></context>
 <previous><!-- 0..1 Reference(ClinicalImpression) Reference to last assessment --></previous>
 <problem><!-- 0..* Reference(Condition|AllergyIntolerance) Relevant impressions of patient state --></problem>
 <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|RiskAssessment|ImagingStudy) Record of a specific investigation --></item>
 </investigations>
 <
 <
 <
  <</item>
  <

 <protocol value="[uri]"/><!-- 0..* Clinical Protocol followed -->
 <summary value="[string]"/><!-- 0..1 Summary of the assessment -->
 <finding>  <!-- 0..* Possible or likely findings and diagnoses -->
  <item[x]><!-- 1..1 CodeableConcept|Reference(Condition|Observation) What was found --></item[x]>
  <cause value="[string]"/><!-- 0..1 Which investigations support finding -->

 </finding>
 <</resolved>
 <
  <</item>
  <
 </ruledOut>
 <
 <|
   |

 <prognosisCodeableConcept><!-- 0..* CodeableConcept Estimate of likely outcome --></prognosisCodeableConcept>
 <prognosisReference><!-- 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome --></prognosisReference>
 <plan><!-- 0..* Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticRequest|MedicationOrder|NutritionRequest|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) Plan of action after assessment --></plan>
 <|
   </action>

 <action><!-- 0..* Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticRequest|NutritionRequest|SupplyRequest|Appointment) Actions taken during assessment --></action>

 <note><!-- 0..* Annotation Comments made about the ClinicalImpression --></note>

</ClinicalImpression>

JSON Template JSON Template { "resourceType" : "", 

{doco
  "resourceType" : "ClinicalImpression",

  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "
  "
  "
  "
  "
  "
  
  " },
  " },
  "
    "
    "|
    
  }],
  "
  "
  "
    "
    "

  "identifier" : [{ Identifier }], // Business identifier
  "status" : "<code>", // R!  draft | completed | entered-in-error
  "code" : { CodeableConcept }, // Kind of impression performed
  "description" : "<string>", // Why/how the assessment was performed
  "subject" : { Reference(Patient|Group) }, // R!  Patient or group assessed
  "assessor" : { Reference(Practitioner) }, // The clinician performing the assessment
  "date" : "<dateTime>", // When the assessment was documented
  // effective[x]: Time of assessment. One of these 2:

  "effectiveDateTime" : "<dateTime>",
  "effectivePeriod" : { Period },
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Encounter or Episode created from
  "previous" : { Reference(ClinicalImpression) }, // Reference to last assessment
  "problem" : [{ Reference(Condition|AllergyIntolerance) }], // Relevant impressions of patient state
  "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|RiskAssessment|ImagingStudy) }] // Record of a specific investigation
  }],
  "
  "
    "
    "

  "protocol" : ["<uri>"], // Clinical Protocol followed
  "summary" : "<string>", // Summary of the assessment
  "finding" : [{ // Possible or likely findings and diagnoses
    // item[x]: What was found. One of these 2:

    "itemCodeableConcept" : { CodeableConcept },
    "itemReference" : { Reference(Condition|Observation) },
    "cause" : "<string>" // Which investigations support finding

  }],
  "
  "|
   |

  "prognosisCodeableConcept" : [{ CodeableConcept }], // Estimate of likely outcome
  "prognosisReference" : [{ Reference(RiskAssessment) }], // RiskAssessment expressing likely outcome
  "plan" : [{ Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticRequest|MedicationOrder|NutritionRequest|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) }], // Plan of action after assessment
  "|
   

  "action" : [{ Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticRequest|NutritionRequest|SupplyRequest|Appointment) }], // Actions taken during assessment

  "note" : [{ Annotation }] // Comments made about the ClinicalImpression

}
 
Alternate
definitions:

Turtle Template 


@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClinicalImpression;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClinicalImpression.identifier [ Identifier ], ... ; # 0..* Business identifier
  fhir:ClinicalImpression.status [ code ]; # 1..1 draft | completed | entered-in-error
  fhir:ClinicalImpression.code [ CodeableConcept ]; # 0..1 Kind of impression performed
  fhir:ClinicalImpression.description [ string ]; # 0..1 Why/how the assessment was performed
  fhir:ClinicalImpression.subject [ Reference(Patient|Group) ]; # 1..1 Patient or group assessed
  fhir:ClinicalImpression.assessor [ Reference(Practitioner) ]; # 0..1 The clinician performing the assessment
  fhir:ClinicalImpression.date [ dateTime ]; # 0..1 When the assessment was documented
  # ClinicalImpression.effective[x] : 0..1 Time of assessment. One of these 2
    fhir:ClinicalImpression.effectiveDateTime [ dateTime ]
    fhir:ClinicalImpression.effectivePeriod [ Period ]
  fhir:ClinicalImpression.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Encounter or Episode created from
  fhir:ClinicalImpression.previous [ Reference(ClinicalImpression) ]; # 0..1 Reference to last assessment
  fhir:ClinicalImpression.problem [ Reference(Condition|AllergyIntolerance) ], ... ; # 0..* Relevant impressions of patient state
  fhir:ClinicalImpression.investigations [ # 0..* One or more sets of investigations (signs, symptions, etc.)
    fhir:ClinicalImpression.investigations.code [ CodeableConcept ]; # 1..1 A name/code for the set
    fhir:ClinicalImpression.investigations.item [ Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|DiagnosticReport|
  RiskAssessment|ImagingStudy) ], ... ; # 0..* Record of a specific investigation

  ], ...;
  fhir:ClinicalImpression.protocol [ uri ], ... ; # 0..* Clinical Protocol followed
  fhir:ClinicalImpression.summary [ string ]; # 0..1 Summary of the assessment
  fhir:ClinicalImpression.finding [ # 0..* Possible or likely findings and diagnoses
    # ClinicalImpression.finding.item[x] : 1..1 What was found. One of these 2
      fhir:ClinicalImpression.finding.itemCodeableConcept [ CodeableConcept ]
      fhir:ClinicalImpression.finding.itemReference [ Reference(Condition|Observation) ]
    fhir:ClinicalImpression.finding.cause [ string ]; # 0..1 Which investigations support finding
  ], ...;
  fhir:ClinicalImpression.prognosisCodeableConcept [ CodeableConcept ], ... ; # 0..* Estimate of likely outcome
  fhir:ClinicalImpression.prognosisReference [ Reference(RiskAssessment) ], ... ; # 0..* RiskAssessment expressing likely outcome
  fhir:ClinicalImpression.plan [ Reference(CarePlan|Appointment|CommunicationRequest|DeviceUseRequest|DiagnosticRequest|
  MedicationOrder|NutritionRequest|ProcedureRequest|ProcessRequest|
  ReferralRequest|SupplyRequest|VisionPrescription) ], ... ; # 0..* Plan of action after assessment

  fhir:ClinicalImpression.action [ Reference(ReferralRequest|ProcedureRequest|Procedure|MedicationOrder|DiagnosticRequest|
  NutritionRequest|SupplyRequest|Appointment) ], ... ; # 0..* Actions taken during assessment

  fhir:ClinicalImpression.note [ Annotation ], ... ; # 0..* Comments made about the ClinicalImpression
]

Changes since DSTU2

ClinicalImpression
ClinicalImpression.identifier added
ClinicalImpression.code added
ClinicalImpression.subject Renamed from patient to subject
Add Reference(Group)
ClinicalImpression.effective[x] added
ClinicalImpression.context added
ClinicalImpression.investigations.item Add Reference(RiskAssessment), Add Reference(ImagingStudy)
ClinicalImpression.protocol Max Cardinality changed from 1 to *
ClinicalImpression.finding.item[x] Renamed from item to item[x]
Add Reference(Condition), Add Reference(Observation)
ClinicalImpression.prognosisCodeableConcept added
ClinicalImpression.prognosisReference added
ClinicalImpression.plan Remove Reference(DiagnosticOrder), Remove Reference(NutritionOrder), Remove Reference(Order), Add Reference(DiagnosticRequest), Add Reference(NutritionRequest)
ClinicalImpression.action Remove Reference(DiagnosticOrder), Remove Reference(NutritionOrder), Add Reference(DiagnosticRequest), Add Reference(NutritionRequest)
ClinicalImpression.note added
ClinicalImpression.trigger[x] deleted
ClinicalImpression.resolved deleted
ClinicalImpression.ruledOut deleted
ClinicalImpression.prognosis deleted

See the Full Difference for further information

 

Alternate definitions: Master Definition ( XML , JSON ), XML Schema / Schematron , Resource Profile ( XML , (for ) + JSON Schema , ShEx (for Turtle ), Questionnaire )

4.6.4.1 Terminology Bindings 9.6.4.1 Terminology Bindings

ClinicalImpression.status ClinicalImpression.trigger[x] ClinicalImpression.investigations.code ClinicalImpression.finding.item ClinicalImpression.resolved ClinicalImpression.ruledOut.item
Path Definition Type Reference
ClinicalImpression.status The workflow state of a clinical impression. The workflow state of a clinical impression. Required ClinicalImpressionStatus
ClinicalImpression.code Identifies categories of clinical impressions. This is a place-holder only. It may be removed Unknown Clinical Findings that may cause an clinical evaluation. No details provided yet
ClinicalImpression.investigations.code A name/code for a set of investigations. Example SNOMED CT Clinical Findings Investigation Type
ClinicalImpression.finding.item[x] A name/code for a set of investigations. Identification of the Condition or diagnosis. Example Condition/Diagnosis Certainty Condition/Problem/Diagnosis Codes
ClinicalImpression.prognosisCodeableConcept Identification of the Condition or diagnosis. Prognosis or outlook findings Example Condition/Problem/Diagnosis Codes Clinical Impression Prognosis

4.6.5 Search Parameters 9.6.5 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.

resolved token Diagnoses/conditions resolved since previous assessment ClinicalImpression.resolved ruledout token Specific text of code for diagnosis ClinicalImpression.ruledOut.item © HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search | Version History | Table of Contents | Compare to DSTU1
Name Type Description Paths
action reference Actions taken during assessment Actions taken during assessment ClinicalImpression.action
( ReferralRequest , Appointment , , ReferralRequest , NutritionRequest , ProcedureRequest , SupplyRequest , , Procedure , , MedicationOrder , NutritionOrder , DiagnosticOrder , DiagnosticRequest , SupplyRequest )
assessor reference The clinician performing the assessment The clinician performing the assessment ClinicalImpression.assessor
( Practitioner )
context reference Encounter or Episode created from ClinicalImpression.context
( EpisodeOfCare , Encounter )
date date When the assessment occurred When the assessment was documented ClinicalImpression.date
finding finding-code token Specific text or code for finding What was found ClinicalImpression.finding.item ClinicalImpression.finding.item[x]
investigation finding-ref reference Record of a specific What was found ClinicalImpression.finding.item[x]
( Condition , Observation )
investigation reference Record of a specific investigation ClinicalImpression.investigations.item
( RiskAssessment , FamilyMemberHistory , , Observation , QuestionnaireResponse , , DiagnosticReport , ImagingStudy , QuestionnaireResponse )
patient reference The patient being assessed Patient or group assessed ClinicalImpression.patient ClinicalImpression.subject
( Patient )
plan reference Plan of action after assessment Plan of action after assessment ClinicalImpression.plan
( CarePlan , ReferralRequest , ProcedureRequest , Appointment , CommunicationRequest , Order , SupplyRequest , VisionPrescription , MedicationOrder , , ReferralRequest , CarePlan , NutritionRequest , ProcessRequest , , VisionPrescription , ProcedureRequest , DeviceUseRequest , NutritionOrder , DiagnosticOrder , MedicationOrder , DiagnosticRequest , CommunicationRequest , SupplyRequest )
previous reference Reference to last assessment Reference to last assessment ClinicalImpression.previous
( ClinicalImpression )
problem reference General assessment of patient state Relevant impressions of patient state ClinicalImpression.problem
( Condition , , AllergyIntolerance )
status token in-progress | completed | entered-in-error draft | completed | entered-in-error ClinicalImpression.status
trigger subject reference Request or event that necessitated this assessment Patient or group assessed ClinicalImpression.triggerReference ClinicalImpression.subject
(Any) trigger-code token ( Group , Patient Request or event that necessitated this assessment ClinicalImpression.triggerCodeableConcept )