FHIR Clinical Guidelines (v1.0.0) (STU1)

Clinical Practice Guidelines, published by Clinical Decision Support WG. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/cqf-recommendations/ and changes regularly. See the Directory of published versions

D.4.1 StructureDefinition-cpg-clinicalimpression

Introduction:

Examples:

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is:

http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-clinicalimpression

CPG Clinical Impression captures clinician judgement at any particular point, and related to the case features and pathway, strategies, and recommendations.

This profile builds on ClinicalImpression.

This profile was published on Thu Jun 06 00:00:00 UTC 2019 as a draft by Health Level Seven, Inc. - CDS WG.

Description of Profiles, Differentials, and Snapshots.

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... cpg-impressionFor S0..1Reference(CPGCase)Which case
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor
... identifier S0..*IdentifierBusiness identifier
... status S1..1codein-progress | completed | entered-in-error
... code S0..1CodeableConceptKind of assessment performed
... description S0..1stringWhy/how the assessment was performed
... subject S1..1Reference(CPGPatient)Patient or group assessed
... encounter S0..1Reference(CPGEncounter)Encounter created as part of
... effective[x] S0..1dateTime, PeriodTime of assessment
... date S0..1dateTimeWhen the assessment was documented
... assessor S0..1Reference(CPGPractitioner | CPGPractitionerRole)The clinician performing the assessment
... protocol S0..*uriClinical Protocol followed

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... cpg-impressionFor S0..1Reference(CPGCase)Which case
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness identifier
... status ?!SΣ1..1codein-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.

... statusReason 0..1CodeableConceptReason for current status
Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.

... code SΣ0..1CodeableConceptKind of assessment performed
Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.

... description SΣ0..1stringWhy/how the assessment was performed
... subject SΣ1..1Reference(CPGPatient)Patient or group assessed
... encounter SΣ0..1Reference(CPGEncounter)Encounter created as part of
... effective[x] SΣ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... date SΣ0..1dateTimeWhen the assessment was documented
... assessor SΣ0..1Reference(CPGPractitioner | CPGPractitionerRole)The clinician performing the assessment
... previous 0..1Reference(ClinicalImpression)Reference to last assessment
... problem Σ0..*Reference(Condition | AllergyIntolerance)Relevant impressions of patient state
... investigation 0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1CodeableConceptA name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.

.... item 0..*Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)Record of a specific investigation
... protocol S0..*uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... finding 0..*BackboneElementPossible or likely findings and diagnoses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1CodeableConceptWhat was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.

.... itemReference 0..1Reference(Condition | Observation | Media)What was found
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.


... prognosisReference 0..*Reference(RiskAssessment)RiskAssessment expressing likely outcome
... supportingInfo 0..*Reference(Resource)Information supporting the clinical impression
... note 0..*AnnotationComments made about the ClinicalImpression

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... cpg-impressionFor S0..1Reference(CPGCase)Which case
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor
... identifier S0..*IdentifierBusiness identifier
... status S1..1codein-progress | completed | entered-in-error
... code S0..1CodeableConceptKind of assessment performed
... description S0..1stringWhy/how the assessment was performed
... subject S1..1Reference(CPGPatient)Patient or group assessed
... encounter S0..1Reference(CPGEncounter)Encounter created as part of
... effective[x] S0..1dateTime, PeriodTime of assessment
... date S0..1dateTimeWhen the assessment was documented
... assessor S0..1Reference(CPGPractitioner | CPGPractitionerRole)The clinician performing the assessment
... protocol S0..*uriClinical Protocol followed

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... cpg-impressionFor S0..1Reference(CPGCase)Which case
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness identifier
... status ?!SΣ1..1codein-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.

... statusReason 0..1CodeableConceptReason for current status
Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.

... code SΣ0..1CodeableConceptKind of assessment performed
Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.

... description SΣ0..1stringWhy/how the assessment was performed
... subject SΣ1..1Reference(CPGPatient)Patient or group assessed
... encounter SΣ0..1Reference(CPGEncounter)Encounter created as part of
... effective[x] SΣ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... date SΣ0..1dateTimeWhen the assessment was documented
... assessor SΣ0..1Reference(CPGPractitioner | CPGPractitionerRole)The clinician performing the assessment
... previous 0..1Reference(ClinicalImpression)Reference to last assessment
... problem Σ0..*Reference(Condition | AllergyIntolerance)Relevant impressions of patient state
... investigation 0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1CodeableConceptA name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.

.... item 0..*Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)Record of a specific investigation
... protocol S0..*uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... finding 0..*BackboneElementPossible or likely findings and diagnoses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1CodeableConceptWhat was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.

.... itemReference 0..1Reference(Condition | Observation | Media)What was found
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.


... prognosisReference 0..*Reference(RiskAssessment)RiskAssessment expressing likely outcome
... supportingInfo 0..*Reference(Resource)Information supporting the clinical impression
... note 0..*AnnotationComments made about the ClinicalImpression

doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathConformanceValueSet
ClinicalImpression.languagepreferredCommonLanguages
Max Binding: AllLanguages
ClinicalImpression.statusrequiredClinicalImpressionStatus
ClinicalImpression.statusReasonexample
ClinicalImpression.codeexample
ClinicalImpression.investigation.codeexampleInvestigationType
ClinicalImpression.finding.itemCodeableConceptexampleCondition/Problem/DiagnosisCodes
ClinicalImpression.prognosisCodeableConceptexampleClinicalImpressionPrognosis

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2ClinicalImpressionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3ClinicalImpressionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4ClinicalImpressionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5ClinicalImpressionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6ClinicalImpressionA resource should have narrative for robust management
: text.`div`.exists()
ele-1ClinicalImpression.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClinicalImpression.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClinicalImpression.extension:impressionForAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClinicalImpression.extension:impressionForMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClinicalImpression.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClinicalImpression.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClinicalImpression.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.statusReasonAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.descriptionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.effective[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.dateAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.assessorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.previousAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.problemAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.investigationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.investigation.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClinicalImpression.investigation.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClinicalImpression.investigation.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClinicalImpression.investigation.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClinicalImpression.investigation.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.investigation.itemAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.protocolAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.summaryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.findingAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.finding.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClinicalImpression.finding.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClinicalImpression.finding.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClinicalImpression.finding.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClinicalImpression.finding.itemCodeableConceptAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.finding.itemReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.finding.basisAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.prognosisCodeableConceptAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.prognosisReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.supportingInfoAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClinicalImpression.noteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())