HL7 PT FHIR Implementation Guide: Example IG Release 1 | STU1
1.0.0 - STU1
HL7 PT FHIR Implementation Guide: Example IG Release 1 | STU1
1.0.0 - STU1
HL7 PT FHIR Implementation Guide: Example IG Release 1 | STU1, published by HL7 Portugal. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/AnaCeciliaCoimbra/community-health-ig/ and changes regularly. See the Directory of published versions
| Official URL: http://example.com/fhir/example/StructureDefinition/ClinicalImpressionEncounter | Version: 1.0.0 | |||
| Active as of 2024-10-08 | Computable Name: ClinicalImpressionEncounter | |||
Este perfil representa as restrições aplicadas ao recurso ClinicalImpression pelo Guia de Implementação FHIR do Sistema Clínico de Triagem e Aconselhamento (TCCS). Descreve as expectativas mínimas para o recurso ClinicalImpression quando utilizado na composição do sistema ou em um dos recursos referidos.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClinicalImpression
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
  subject |
1..1 | Reference(Patient (TCCS)) | Patient or group assessed | |
 encounter |
1..1 | Reference(Encounter) | Encounter created as part of | |
 assessor |
1..1 | Reference(Practitioner) | The clinician performing the assessment | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!Σ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. |
| subject |
Σ | 1..1 | Reference(Patient (TCCS)) | Patient or group assessed |
| encounter |
Σ | 1..1 | Reference(Encounter) | Encounter created as part of |
| assessor |
Σ | 1..1 | Reference(Practitioner) | The clinician performing the assessment |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1from the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClinicalImpression | If 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-4 | error | ClinicalImpression | If 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-5 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClinicalImpression | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
 meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifier | ||||
| status |
?!Σ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. | ||||
| statusReason |
0..1 | CodeableConcept | Reason for current status Binding Description (No ValueSet): (example): Codes identifying the reason for the current state of a clinical impression. | |||||
| code |
Σ | 0..1 | CodeableConcept | Kind of assessment performed Binding Description (No ValueSet): (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. | ||||
| description |
Σ | 0..1 | string | Why/how the assessment was performed | ||||
| subject |
Σ | 1..1 | Reference(Patient (TCCS)) | Patient or group assessed | ||||
| encounter |
Σ | 1..1 | Reference(Encounter) | Encounter created as part of | ||||
  effective[x] |
Σ | 0..1 | Time of assessment | |||||
 effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| date |
Σ | 0..1 | dateTime | When the assessment was documented | ||||
| assessor |
Σ | 1..1 | Reference(Practitioner) | 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 | ||||
| investigation |
0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
1..1 | CodeableConcept | A 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 |
0..* | uri | Clinical Protocol followed | |||||
| summary |
0..1 | string | Summary of the assessment | |||||
| finding |
0..* | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemCodeableConcept |
0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
0..1 | string | Which investigations support finding | |||||
| prognosisCodeableConcept |
0..* | CodeableConcept | Estimate 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..* | Annotation | Comments made about the ClinicalImpression | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| ClinicalImpression.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1from the FHIR Standard | ||||
| ClinicalImpression.statusReason | example | |||||
| ClinicalImpression.code | example | |||||
| ClinicalImpression.investigation.code | example | InvestigationTypehttp://hl7.org/fhir/ValueSet/investigation-setsfrom the FHIR Standard | ||||
| ClinicalImpression.finding.itemCodeableConcept | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| ClinicalImpression.prognosisCodeableConcept | example | ClinicalImpressionPrognosishttp://hl7.org/fhir/ValueSet/clinicalimpression-prognosisfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClinicalImpression | If 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-4 | error | ClinicalImpression | If 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-5 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClinicalImpression | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ClinicalImpression
Differential View
This structure is derived from ClinicalImpression
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
| subject |
1..1 | Reference(Patient (TCCS)) | Patient or group assessed | |
| encounter |
1..1 | Reference(Encounter) | Encounter created as part of | |
| assessor |
1..1 | Reference(Practitioner) | The clinician performing the assessment | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!Σ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. |
| subject |
Σ | 1..1 | Reference(Patient (TCCS)) | Patient or group assessed |
| encounter |
Σ | 1..1 | Reference(Encounter) | Encounter created as part of |
| assessor |
Σ | 1..1 | Reference(Practitioner) | The clinician performing the assessment |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1from the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClinicalImpression | If 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-4 | error | ClinicalImpression | If 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-5 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClinicalImpression | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifier | ||||
| status |
?!Σ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. | ||||
| statusReason |
0..1 | CodeableConcept | Reason for current status Binding Description (No ValueSet): (example): Codes identifying the reason for the current state of a clinical impression. | |||||
| code |
Σ | 0..1 | CodeableConcept | Kind of assessment performed Binding Description (No ValueSet): (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. | ||||
| description |
Σ | 0..1 | string | Why/how the assessment was performed | ||||
| subject |
Σ | 1..1 | Reference(Patient (TCCS)) | Patient or group assessed | ||||
| encounter |
Σ | 1..1 | Reference(Encounter) | Encounter created as part of | ||||
| effective[x] |
Σ | 0..1 | Time of assessment | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| date |
Σ | 0..1 | dateTime | When the assessment was documented | ||||
| assessor |
Σ | 1..1 | Reference(Practitioner) | 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 | ||||
| investigation |
0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
1..1 | CodeableConcept | A 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 |
0..* | uri | Clinical Protocol followed | |||||
| summary |
0..1 | string | Summary of the assessment | |||||
| finding |
0..* | BackboneElement | Possible or likely findings and diagnoses | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemCodeableConcept |
0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
| itemReference |
0..1 | Reference(Condition | Observation | Media) | What was found | |||||
| basis |
0..1 | string | Which investigations support finding | |||||
| prognosisCodeableConcept |
0..* | CodeableConcept | Estimate 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..* | Annotation | Comments made about the ClinicalImpression | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| ClinicalImpression.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1from the FHIR Standard | ||||
| ClinicalImpression.statusReason | example | |||||
| ClinicalImpression.code | example | |||||
| ClinicalImpression.investigation.code | example | InvestigationTypehttp://hl7.org/fhir/ValueSet/investigation-setsfrom the FHIR Standard | ||||
| ClinicalImpression.finding.itemCodeableConcept | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| ClinicalImpression.prognosisCodeableConcept | example | ClinicalImpressionPrognosishttp://hl7.org/fhir/ValueSet/clinicalimpression-prognosisfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClinicalImpression | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClinicalImpression | If 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-4 | error | ClinicalImpression | If 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-5 | error | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClinicalImpression | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ClinicalImpression
Other representations of profile: CSV, Excel, Schematron