Clinical Practice Guidelines
2.0.0-ballot - ballot International flag

Clinical Practice Guidelines, published by HL7 International / Clinical Decision Support. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/cqf-recommendations/ and changes regularly. See the Directory of published versions

Resource Profile: CPG Clinical Impression

Official URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-clinicalimpression Version: 2.0.0-ballot
Active as of 2023-12-19 Computable Name: CPGClinicalImpression

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

This is a domain instance profile

Examples:

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... impressionFor S0..1base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, MetaCPG Impression For Extension
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor
... identifier S0..*IdentifierBusiness identifier
... code S0..1CodeableConceptKind of assessment performed
... description S0..1stringWhy/how the assessment was performed
... subject S1..1Reference(CPG Patient)Patient or group assessed
... encounter S0..1Reference(CPG Encounter)Encounter created as part of
... effective[x] S0..1dateTime, PeriodTime of assessment
... date S0..1dateTimeWhen the assessment was documented
... assessor S0..1Reference(CPG Practitioner | CPG Practitioner Role)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
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... impressionFor S0..1base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, MetaCPG Impression For Extension
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor
... identifier SΣ0..*IdentifierBusiness identifier
... status ?!SΣ1..1codein-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow 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(CPG Patient)Patient or group assessed
... encounter SΣ0..1Reference(CPG Encounter)Encounter created as part of
... effective[x] SΣ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... date SΣ0..1dateTimeWhen the assessment was documented
... assessor SΣ0..1Reference(CPG Practitioner | CPG Practitioner Role)The clinician performing the assessment
... protocol S0..*uriClinical Protocol followed

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClinicalImpression.statusrequiredClinicalImpressionStatus
ClinicalImpression.codeexample

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClinicalImpressionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClinicalImpressionIf 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-4errorClinicalImpressionIf 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-5errorClinicalImpressionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClinicalImpressionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... id Σ0..1idLogical 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): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... impressionFor S0..1base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, MetaCPG Impression For Extension
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(CPG Patient)Patient or group assessed
... encounter SΣ0..1Reference(CPG Encounter)Encounter created as part of
... effective[x] SΣ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... date SΣ0..1dateTimeWhen the assessment was documented
... assessor SΣ0..1Reference(CPG Practitioner | CPG Practitioner Role)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

Terminology Bindings

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

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClinicalImpressionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClinicalImpressionIf 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-4errorClinicalImpressionIf 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-5errorClinicalImpressionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClinicalImpressionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... impressionFor S0..1base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, MetaCPG Impression For Extension
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor
... identifier S0..*IdentifierBusiness identifier
... code S0..1CodeableConceptKind of assessment performed
... description S0..1stringWhy/how the assessment was performed
... subject S1..1Reference(CPG Patient)Patient or group assessed
... encounter S0..1Reference(CPG Encounter)Encounter created as part of
... effective[x] S0..1dateTime, PeriodTime of assessment
... date S0..1dateTimeWhen the assessment was documented
... assessor S0..1Reference(CPG Practitioner | CPG Practitioner Role)The clinician performing the assessment
... protocol S0..*uriClinical Protocol followed

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... impressionFor S0..1base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, MetaCPG Impression For Extension
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor
... identifier SΣ0..*IdentifierBusiness identifier
... status ?!SΣ1..1codein-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow 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(CPG Patient)Patient or group assessed
... encounter SΣ0..1Reference(CPG Encounter)Encounter created as part of
... effective[x] SΣ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... date SΣ0..1dateTimeWhen the assessment was documented
... assessor SΣ0..1Reference(CPG Practitioner | CPG Practitioner Role)The clinician performing the assessment
... protocol S0..*uriClinical Protocol followed

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClinicalImpression.statusrequiredClinicalImpressionStatus
ClinicalImpression.codeexample

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClinicalImpressionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClinicalImpressionIf 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-4errorClinicalImpressionIf 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-5errorClinicalImpressionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClinicalImpressionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... id Σ0..1idLogical 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): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... impressionFor S0..1base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, MetaCPG Impression For Extension
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(CPG Patient)Patient or group assessed
... encounter SΣ0..1Reference(CPG Encounter)Encounter created as part of
... effective[x] SΣ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... date SΣ0..1dateTimeWhen the assessment was documented
... assessor SΣ0..1Reference(CPG Practitioner | CPG Practitioner Role)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

Terminology Bindings

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

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClinicalImpressionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClinicalImpressionIf 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-4errorClinicalImpressionIf 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-5errorClinicalImpressionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClinicalImpressionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron