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Patient Care Work GroupMaturity Level: 0 Trial UseSecurity Category: Patient Compartments: Encounter, Patient, Practitioner

Detailed Descriptions for the elements in the ClinicalImpression resource.

ClinicalImpression
Element IdClinicalImpression
Definition

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.

Cardinality0..*
TypeDomainResource
ClinicalImpression.identifier
Element IdClinicalImpression.identifier
Definition

Business identifiers assigned to this clinical impression by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Requirements

Allows identification of the clinical impression as it is known by various participating systems and in a way that remains consistent across servers.

Summarytrue
Comments

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

ClinicalImpression.status
Element IdClinicalImpression.status
Definition

Identifies the workflow status of the assessment.

Cardinality1..1
Terminology BindingClinical Impression Status (Required)
Typecode
Is Modifiertrue (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summarytrue
Comments

This element is labeled as a modifier because the status contains the code entered-in-error that marks the clinical impression as not currently valid.

ClinicalImpression.statusReason
Element IdClinicalImpression.statusReason
Definition

Captures the reason for the current state of the ClinicalImpression.

Cardinality0..1
Terminology BindingClinicalImpressionStatusReason:
TypeCodeableConcept
Alternate NamesSuspended Reason; Cancelled Reason
Comments

This is generally only used for "exception" statuses such as "not-done", "suspended" or "cancelled".

[distinct reason codes for different statuses can be enforced using invariants if they are universal bindings].

ClinicalImpression.code
Element IdClinicalImpression.code
Definition

Categorizes the type of clinical assessment performed.

Cardinality0..1
Terminology BindingClinicalImpressionCode:
TypeCodeableConcept
Alternate Namestype
Summarytrue
Comments

This is present as a place-holder only and may be removed based on feedback/work group opinion.

ClinicalImpression.description
Element IdClinicalImpression.description
Definition

A summary of the context and/or cause of the assessment - why / where it was performed, and what patient events/status prompted it.

Cardinality0..1
Typestring
Summarytrue
ClinicalImpression.subject
Element IdClinicalImpression.subject
Definition

The patient or group of individuals assessed as part of this record.

Cardinality1..1
TypeReference(Patient | Group)
Requirements

Group is typically for veterinary and/or public health purposes.

Summarytrue
ClinicalImpression.encounter
Element IdClinicalImpression.encounter
Definition

The Encounter during which this ClinicalImpression was created or to which the creation of this record is tightly associated.

Cardinality0..1
TypeReference(Encounter)
Summarytrue
Comments

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

ClinicalImpression.effective[x]
Element IdClinicalImpression.effective[x]
Definition

The point in time or period over which the subject was assessed.

Cardinality0..1
TypedateTime|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Comments

This SHOULD be accurate to at least the minute, though some assessments only have a known date.

ClinicalImpression.date
Element IdClinicalImpression.date
Definition

Indicates when the documentation of the assessment was complete.

Cardinality0..1
TypedateTime
Summarytrue
ClinicalImpression.assessor
Element IdClinicalImpression.assessor
Definition

The clinician performing the assessment.

Cardinality0..1
TypeReference(Practitioner | PractitionerRole)
Summarytrue
ClinicalImpression.previous
Element IdClinicalImpression.previous
Definition

A reference to the last assessment that was conducted on 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.

Cardinality0..1
TypeReference(ClinicalImpression)
Comments

It is always likely that multiple previous assessments exist for a patient. The point of quoting a previous assessment is that this assessment is relative to it (see resolved).

ClinicalImpression.problem
Element IdClinicalImpression.problem
Definition

A list of the relevant problems/conditions for a patient.

Cardinality0..*
TypeReference(Condition | AllergyIntolerance)
Summarytrue
Comments

e.g. The patient is a pregnant, has congestive heart failure, has an ‎Adenocarcinoma, and is allergic to penicillin.

ClinicalImpression.investigation
Element IdClinicalImpression.investigation
Definition

One or more sets of investigations (signs, symptoms, etc.). The actual grouping of investigations varies 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.

Cardinality0..*
ClinicalImpression.investigation.code
Element IdClinicalImpression.investigation.code
Definition

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|nutritional) history may be used.

Cardinality1..1
Terminology BindingInvestigation Type (Example)
TypeCodeableConcept
ClinicalImpression.investigation.item
Element IdClinicalImpression.investigation.item
Definition

A record of a specific investigation that was undertaken.

Cardinality0..*
TypeReference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)
Comments

Most investigations are observations of one kind or another but some other specific types of data collection resources can also be used.

ClinicalImpression.protocol
Element IdClinicalImpression.protocol
Definition

Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.

Cardinality0..*
Typeuri
ClinicalImpression.summary
Element IdClinicalImpression.summary
Definition

A text summary of the investigations and the diagnosis.

Cardinality0..1
Typestring
ClinicalImpression.finding
Element IdClinicalImpression.finding
Definition

Specific findings or diagnoses that were considered likely or relevant to ongoing treatment.

Cardinality0..*
ClinicalImpression.finding.itemCodeableConcept
Element IdClinicalImpression.finding.itemCodeableConcept
Definition

Specific text or code for finding or diagnosis, which may include ruled-out or resolved conditions.

Cardinality0..1
Terminology BindingCondition/Problem/Diagnosis Codes (Example)
TypeCodeableConcept
ClinicalImpression.finding.itemReference
Element IdClinicalImpression.finding.itemReference
Definition

Specific reference for finding or diagnosis, which may include ruled-out or resolved conditions.

Cardinality0..1
TypeReference(Condition | Observation | Media)
ClinicalImpression.finding.basis
Element IdClinicalImpression.finding.basis
Definition

Which investigations support finding or diagnosis.

Cardinality0..1
Typestring
ClinicalImpression.prognosisCodeableConcept
Element IdClinicalImpression.prognosisCodeableConcept
Definition

Estimate of likely outcome.

Cardinality0..*
Terminology BindingClinical Impression Prognosis (Example)
TypeCodeableConcept
ClinicalImpression.prognosisReference
Element IdClinicalImpression.prognosisReference
Definition

RiskAssessment expressing likely outcome.

Cardinality0..*
TypeReference(RiskAssessment)
ClinicalImpression.supportingInfo
Element IdClinicalImpression.supportingInfo
Definition

Information supporting the clinical impression.

Cardinality0..*
TypeReference(Any)
ClinicalImpression.note
Element IdClinicalImpression.note
Definition

Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear.

Cardinality0..*
TypeAnnotation
Comments

Don't use this element for content that should more properly appear as one of the specific elements of the impression.