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Patient Care icon 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.

Short DisplayA clinical assessment performed when planning treatments and management strategies for a patient
Cardinality0..*
TypeDomainResource
Summaryfalse
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.

Short DisplayBusiness identifier
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.

Short Displaypreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Cardinality1..1
Terminology BindingEventStatus (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.

Short DisplayReason for current status
Cardinality0..1
Terminology BindingClinicalImpression Status Reason (Example)
TypeCodeableConcept
Alternate NamesSuspended Reason; Cancelled Reason
Summaryfalse
Comments

This is generally only used for "exception" statuses such as "not-done", "on-hold" or "stopped".

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.

Short DisplayWhy/how the assessment was performed
Cardinality0..1
Typestring
Summarytrue
ClinicalImpression.subject
Element IdClinicalImpression.subject
Definition

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

Short DisplayPatient or group assessed
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.

Short DisplayThe Encounter during which this ClinicalImpression was created
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.

Short DisplayTime of assessment
Cardinality0..1
TypedateTime|Period
[x] NoteSee Choice of Datatypes 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.

Short DisplayWhen the assessment was documented
Cardinality0..1
TypedateTime
Summarytrue
ClinicalImpression.performer
Element IdClinicalImpression.performer
Definition

The clinician performing the assessment.

Short DisplayThe 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.

Short DisplayReference to last assessment
Cardinality0..1
TypeReference(ClinicalImpression)
Summaryfalse
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.

Short DisplayRelevant impressions of patient state
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.changePattern
Element IdClinicalImpression.changePattern
Definition

Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change. It is a subjective assessment of the direction of the change.

Short DisplayChange in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change
Cardinality0..1
Terminology BindingClinicalImpression Change Pattern (Example)
TypeCodeableConcept
Summaryfalse
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.

Short DisplayClinical Protocol followed
Cardinality0..*
Typeuri
Summaryfalse
ClinicalImpression.summary
Element IdClinicalImpression.summary
Definition

A text summary of the investigations and the diagnosis.

Short DisplaySummary of the assessment
Cardinality0..1
Typestring
Summaryfalse
ClinicalImpression.finding
Element IdClinicalImpression.finding
Definition

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

Short DisplayPossible or likely findings and diagnoses
Cardinality0..*
Summaryfalse
ClinicalImpression.finding.item
Element IdClinicalImpression.finding.item
Definition

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

Short DisplayWhat was found
Cardinality0..1
Terminology BindingCondition/Problem/Diagnosis Codes (Example)
TypeCodeableReference(Condition | Observation | DocumentReference)
Summaryfalse
ClinicalImpression.finding.basis
Element IdClinicalImpression.finding.basis
Definition

Which investigations support finding or diagnosis.

Short DisplayWhich investigations support finding
Cardinality0..1
Typestring
Summaryfalse
ClinicalImpression.prognosisCodeableConcept
Element IdClinicalImpression.prognosisCodeableConcept
Definition

Estimate of likely outcome.

Short DisplayEstimate of likely outcome
Cardinality0..*
Terminology BindingClinical Impression Prognosis (Example)
TypeCodeableConcept
Summaryfalse
ClinicalImpression.prognosisReference
Element IdClinicalImpression.prognosisReference
Definition

RiskAssessment expressing likely outcome.

Short DisplayRiskAssessment expressing likely outcome
Cardinality0..*
TypeReference(RiskAssessment)
Summaryfalse
ClinicalImpression.supportingInfo
Element IdClinicalImpression.supportingInfo
Definition

Information supporting the clinical impression, which can contain investigation results.

Short DisplayInformation supporting the clinical impression
Cardinality0..*
TypeReference(Any)
Summaryfalse
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.

Short DisplayComments made about the ClinicalImpression
Cardinality0..*
TypeAnnotation
Summaryfalse
Comments

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