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9.8 Resource ClinicalImpression - Content

Patient Care icon Work GroupMaturity Level: 1 Trial UseSecurity Category: Patient Compartments: Encounter, Group, Patient, Practitioner

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.

9.8.1 Scope and Usage

Performing a clinical assessment is a fundamental part of a clinician's workflow, performed repeatedly throughout the day. In spite of this - or perhaps, because of it - there is wide variance in how clinical impressions are recorded. Some clinical assessments simply result in an impression recorded as a single text note in the patient 'record' (e.g. "Progress satisfactory, continue with treatment"), while others are associated with careful, detailed record keeping of the evidence gathered and the reasoning leading to a differential diagnosis, and there is a continuum between these. This resource is intended to be used to cover all these use cases.

The assessment is intimately linked to the process of care. It may occur in the context of a care plan, and it very often results in a new (or revised) care plan. Normally, clinical assessments are part of an ongoing process of care, and the patient will be re-assessed repeatedly. For this reason, the clinical impression can explicitly reference both care plans (preceding and resulting) and reference a previous impression that this impression follows.

An impression is a clinical summation of information and/or an opinion formed, which is the outcome of the clinical assessment process. The ClinicalImpression may lead to a statement of a Condition about a patient.

In FHIR, an assessment is typically an instrument or tool used to collect information about a patient.

Note to Implementers: Unlike many other resources, there is little prior art with regard to exchanging records of clinical assessments. For this reason, this resource should be regarded as particularly prone to ongoing revision. In terms of scope and usage, the Patient Care workgroup wishes to draw the attention of reviewers and implementers to the following issues:

  • When is an existing clinical impression revised, rather than a new one created (that references the existing one)? How does that affect the status? What's the interplay between the status of the diagnosis and the status of the impression? (e.g. for a 'provisional' impression, which bit is provisional?)
  • This structure doesn't differentiate between a working and a final diagnosis. Given an answer to the previous question, should it?
  • Further clarify around the relationship between care plan and impression is needed. Both answers to the previous questions and ongoing discussions around revisions to the care plan will influence the design of clinical impression
  • Should prognosis be represented, and if so, how much structure should it have?
  • Should an impression reference other impressions that are related? (how related?)
  • Investigations - the specification needs a good value set for the code for the group, and will be considering the name "investigations" further

Feedback is welcome here icon.

9.8.2 Boundaries and Relationships

ClinicalImpression is the equivalent of the "A" (assessment) in the SOAP note format originally described by Lawrence Weed, MD. It is the outcome of the clinical assessment process. The ClinicalImpression may lead to a statement of a Condition about a patient. There is another related clinical concept often called an "assessment": assessment Tools such as Apgar (also known as "Assessment Scales"). This is not what the ClinicalImpression resource is about; assessment tools such as Apgar are represented as Observations, and Questionnaires may be used to help generate these. Clinical Impressions may refer to these assessment tools as one of the investigations that was performed during the assessment process.

9.8.3 Background and Context

An important background to understanding this resource is the FHIR Confluence page for clinical assessment icon. In particular, the storyboards there drove the design of the resource, and will be the basis for all examples created.

PLANNED CHANGE:

ClinicalImpression is one of the Event resources in the FHIR Workflow specification. As such, it is expected to be adjusted to align with the Event workflow pattern which will involve adding a number of additional data elements and potentially renaming a few elements. Any concerns about performing such alignment are welcome as ballot comments and/or tracker items.

9.8.4 References to this Resource

9.8.5 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression TU DomainResource A clinical assessment performed when planning treatments and management strategies for a patient

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 0..* Identifier Business identifier

... status ?!Σ 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (Required)
... statusReason 0..1 CodeableConcept Reason for current status
Binding: ClinicalImpression Status Reason (Example)
... subject Σ 1..1 Reference(Patient | Group) Patient or group assessed
... encounter Σ 0..1 Reference(Encounter) The Encounter during which this ClinicalImpression was created
... effective[x] Σ 0..1 Time of assessment
.... effectiveDateTime dateTime
.... effectivePeriod Period
... date Σ 0..1 dateTime When the assessment was documented
... performer Σ 0..1 Reference(Practitioner | PractitionerRole) The clinician performing the assessment
... previous 0..1 Reference(ClinicalImpression) Reference to last assessment
... problem Σ 0..* Reference(Condition | AllergyIntolerance) Relevant impressions of patient state

... changePattern 0..1 CodeableConcept Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change
Binding: ClinicalImpression Change Pattern (Example)
... protocol 0..* uri Clinical Protocol followed

... summary 0..1 markdown Summary of the assessment
... finding 0..* BackboneElement Possible or likely findings and diagnoses

.... item 0..1 CodeableReference(Condition | Observation | DocumentReference) What was found
Binding: Condition/Problem/Diagnosis Codes (Example)
.... basis 0..1 string Which investigations support finding
... prognosisCodeableConcept 0..* CodeableConcept Estimate of likely outcome
Binding: Clinical Impression Prognosis (Example)

... prognosisReference 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome

... supportingInfo 0..* Reference(Any) Information supporting the clinical impression

... note 0..* Annotation Comments made about the ClinicalImpression


doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

9.8.5.1 Terminology Bindings

Path ValueSet Type Documentation
ClinicalImpression.status EventStatus Required

Codes identifying the lifecycle stage of an event.
ClinicalImpression.statusReason ClinicalImpressionStatusReason Example

Example codes indicating the reason why a ClinicalImpression is on hold or stopped. Note that these are in no way complete and might not even be appropriate for some uses.
ClinicalImpression.changePattern ClinicalImpressionChangePatter Example

Example codes indicating the change pattern of a ClinicalImpression. Note that these are in no way complete and might not even be appropriate for some uses.
ClinicalImpression.finding.item ConditionProblemDiagnosisCodes Example

Example value set for Condition/Problem/Diagnosis codes.
ClinicalImpression.prognosisCodeableConcept ClinicalImpressionPrognosis Example

Example value set for clinical impression prognosis.

9.8.5.2 Known Issue

A known issue exists with circular references between Condition and ClinicalImpression, which is due to the low maturity level of ClinicalImpression. The Patient Care work group intends to address this issue when ClinicalImpression is considered substantially complete and ready for implementation.

9.8.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
date date When the assessment was documented ClinicalImpression.date 26 Resources
encounter reference The Encounter during which this ClinicalImpression was created ClinicalImpression.encounter
(Encounter)		 29 Resources
finding-code token Reference to a concept (by class) ClinicalImpression.finding.item.concept
finding-ref reference Reference to a resource (by instance) ClinicalImpression.finding.item.reference
identifier token Business identifier ClinicalImpression.identifier 65 Resources
patient reference Patient assessed ClinicalImpression.subject.where(resolve() is Patient)
(Patient)		 65 Resources
performer reference The clinician performing the assessment ClinicalImpression.performer
(Practitioner, PractitionerRole)
previous reference Reference to last assessment ClinicalImpression.previous
(ClinicalImpression)
problem reference Relevant impressions of patient state ClinicalImpression.problem
(Condition, AllergyIntolerance)
status token preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown ClinicalImpression.status
subject reference Patient or group assessed ClinicalImpression.subject
(Group, Patient)
supporting-info reference Information supporting the clinical impression ClinicalImpression.supportingInfo
(Any)