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9.8 Resource ClinicalAssessment - 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 "ClinicalAssessment" 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 assessments are recorded. Some clinical assessments simply result in an assessment 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 assessment can explicitly reference both care plans (preceding and resulting) and reference a previous assessment that this assessment follows.

An assessment is a clinical summation of information and/or an opinion formed, which is the outcome of the clinical assessment process. The ClinicalAssessment 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 assessment 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 assessment? (e.g. for a 'provisional' assessment, 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 assessment is needed. Both answers to the previous questions and ongoing discussions around revisions to the care plan will influence the design of clinical assessment
  • Should prognosis be represented, and if so, how much structure should it have?
  • Should an assessment reference other assessments 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

ClinicalAssessment 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 ClinicalAssessment 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 ClinicalAssessment resource is about; assessment tools such as Apgar are represented as Observations, and Questionnaires may be used to help generate these. Clinical assessments 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:

ClinicalAssessment 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
.. ClinicalAssessment 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: ClinicalAssessment 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 ClinicalAssessment 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(ClinicalAssessment) Reference to last assessment
... problem Σ 0..* Reference(Condition | AllergyIntolerance) Relevant assessments 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: ClinicalAssessment Change Pattern (Example)
... protocol 0..* uri Clinical Protocol followed

... summary 0..1 markdown Text 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 assessment Prognosis (Example)

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

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

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


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
ClinicalAssessment.status EventStatus Required

Codes identifying the lifecycle stage of an event.
ClinicalAssessment.statusReason ClinicalAssessmentStatusReason Example

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

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

Example value set for Condition/Problem/Diagnosis codes.
ClinicalAssessment.prognosisCodeableConcept ClinicalAssessmentPrognosis Example

Example value set for clinical assessment prognosis.

9.8.5.2 Known Issue

A known issue exists with circular references between Condition and ClinicalAssessment, which is due to the low maturity level of ClinicalAssessment. The Patient Care work group intends to address this issue when ClinicalAssessment 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 ClinicalAssessment.date
encounter reference The Encounter during which this ClinicalAssessment was created ClinicalAssessment.encounter
(Encounter)
finding-code token Reference to a concept (by class) ClinicalAssessment.finding.item.concept
finding-ref reference Reference to a resource (by instance) ClinicalAssessment.finding.item.reference
identifier token Business identifier ClinicalAssessment.identifier
patient reference Patient assessed ClinicalAssessment.subject.where(resolve() is Patient)
(Patient)
performer reference The clinician performing the assessment ClinicalAssessment.performer
(Practitioner, PractitionerRole)
previous reference Reference to last assessment ClinicalAssessment.previous
(ClinicalAssessment)
problem reference Relevant impressions of patient state ClinicalAssessment.problem
(Condition, AllergyIntolerance)
status token preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown ClinicalAssessment.status
subject reference Patient or group assessed ClinicalAssessment.subject
(Group, Patient)
supporting-info reference Information supporting the clinical impression ClinicalAssessment.supportingInfo
(Any)