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 |