ClinicalImpression
ClinicalImpression
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.
Properties
| Name | Required | Type | Description |
|---|---|---|---|
| identifier | No | Identifier[] | Business identifier |
| status | Yes | code | in-progress / completed / entered-in-error |
| statusReason | No | CodeableConcept | Reason for current status |
| code | No | CodeableConcept | Kind of assessment performed |
| description | No | string | Why/how the assessment was performed |
| subject | Yes | Reference<Patient / Group> | Patient or group assessed |
| encounter | No | Reference<Encounter> | Encounter created as part of |
| effective[x] | No | dateTime, Period | Time of assessment |
| date | No | dateTime | When the assessment was documented |
| assessor | No | Reference<Practitioner / PractitionerRole> | The clinician performing the assessment |
| previous | No | Reference<ClinicalImpression> | Reference to last assessment |
| problem | No | Reference<Condition / AllergyIntolerance>[] | Relevant impressions of patient state |
| investigation | No | ClinicalImpressionInvestigation | One or more sets of investigations (signs, symptoms, etc.) |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - code | Yes | CodeableConcept | A name/code for the set |
| - item | No | Reference<Observation / QuestionnaireResponse / FamilyMemberHistory / DiagnosticReport / RiskAssessment / ImagingStudy / Media>[] | Record of a specific investigation |
| protocol | No | uri[] | Clinical Protocol followed |
| summary | No | string | Summary of the assessment |
| finding | No | ClinicalImpressionFinding | Possible or likely findings and diagnoses |
| - id | No | string | Unique id for inter-element referencing |
| - extension | No | Extension[] | Additional content defined by implementations |
| - modifierExtension | No | Extension[] | Extensions that cannot be ignored even if unrecognized |
| - itemCodeableConcept | No | CodeableConcept | What was found |
| - itemReference | No | Reference<Condition / Observation / Media> | What was found |
| - basis | No | string | Which investigations support finding |
| prognosisCodeableConcept | No | CodeableConcept[] | Estimate of likely outcome |
| prognosisReference | No | Reference<RiskAssessment>[] | RiskAssessment expressing likely outcome |
| supportingInfo | No | Reference<Resource>[] | Information supporting the clinical impression |
| note | No | Annotation[] | Comments made about the ClinicalImpression |
Search Parameters
| Name | Type | Description | Expression |
|---|---|---|---|
| date | date | When the assessment was documented | ClinicalImpression.date |
| patient | reference | Patient or group assessed | ClinicalImpression.subject |
| assessor | reference | The clinician performing the assessment | ClinicalImpression.assessor |
| encounter | reference | Encounter created as part of | ClinicalImpression.encounter |
| finding-code | token | What was found | ClinicalImpression.finding.itemCodeableConcept |
| finding-ref | reference | What was found | ClinicalImpression.finding.itemReference |
| identifier | token | Business identifier | ClinicalImpression.identifier |
| investigation | reference | Record of a specific investigation | ClinicalImpression.investigation.item |
| previous | reference | Reference to last assessment | ClinicalImpression.previous |
| problem | reference | Relevant impressions of patient state | ClinicalImpression.problem |
| status | token | in-progress / completed / entered-in-error | ClinicalImpression.status |
| subject | reference | Patient or group assessed | ClinicalImpression.subject |
| supporting-info | reference | Information supporting the clinical impression | ClinicalImpression.supportingInfo |
Inherited Properties
| Name | Required | Type | Description |
|---|---|---|---|
| id | No | string | Logical id of this artifact |
| meta | No | Meta | Metadata about the resource |
| implicitRules | No | uri | A set of rules under which this content was created |
| language | No | code | Language of the resource content |
| text | No | Narrative | Text summary of the resource, for human interpretation |
| contained | No | Resource[] | Contained, inline Resources |
| extension | No | Extension[] | Additional content defined by implementations |
| modifierExtension | No | Extension[] | Extensions that cannot be ignored |
To view the FHIR specification for this resource, see ClinicalImpression.