ClinicalImpression

draftResource40 elementsv4.0.1

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.

Metadata

hl7.org/fhir

Canonical URL: http://hl7.org/fhir/StructureDefinition/ClinicalImpression
ID: ClinicalImpression
Type
Base Definition
Derivation: specialization
Publisher: Health Level Seven International (Patient Care)
Version: 4.0.1

Path	Card.	Type	Description
`ClinicalImpression`	`0..*`		A clinical assessment performed when planning treatments and management strategies for a patient
`id`	`0..1`	string	Logical id of this artifact
`meta`	`0..1`	Meta	Metadata about the resource
`implicitRules`	`0..1`	uri	A set of rules under which this content was created
`language`	`0..1`	code	Language of the resource contentpreferred: languages
`text`	`0..1`	Narrative	Text summary of the resource, for human interpretation
`contained`	`0..*`	Resource	Contained, inline Resources
`extension`	`0..*`	Extension	Additional content defined by implementations
`modifierExtension`	`0..*`	Extension	Extensions that cannot be ignored
`identifier`	`0..*`	Identifier	Business identifier
`status`	`1..1`	code	in-progress \| completed \| entered-in-errorrequired: clinicalimpression-status
`statusReason`	`0..1`	CodeableConcept	Reason for current status
`code`	`0..1`	CodeableConcept	Kind of assessment performed
`description`	`0..1`	string	Why/how the assessment was performed
`subject`	`1..1`	Reference	Patient or group assessed
`encounter`	`0..1`	Reference	Encounter created as part of
`effective[x]`	`0..1`	dateTimePeriod	Time of assessment
`date`	`0..1`	dateTime	When the assessment was documented
`assessor`	`0..1`	Reference	The clinician performing the assessment
`previous`	`0..1`	Reference	Reference to last assessment
`problem`	`0..*`	Reference	Relevant impressions of patient state
`investigation`	`0..*`	BackboneElement	One or more sets of investigations (signs, symptoms, etc.)
`protocol`	`0..*`	uri	Clinical Protocol followed
`summary`	`0..1`	string	Summary of the assessment
`finding`	`0..*`	BackboneElement	Possible or likely findings and diagnoses
`prognosisCodeableConcept`	`0..*`	CodeableConcept	Estimate of likely outcomeexample: clinicalimpression-prognosis
`prognosisReference`	`0..*`	Reference	RiskAssessment expressing likely outcome
`supportingInfo`	`0..*`	Reference	Information supporting the clinical impression
`note`	`0..*`	Annotation	Comments made about the ClinicalImpression