FHIR R6 Patient Care Incubator
0.1.0 - ci-build International flag

FHIR R6 Patient Care Incubator, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/pc-incubator/ and changes regularly. See the Directory of published versions

Resource Profile: Clinical assessment

Official URL: http://hl7.org/fhir/StructureDefinition/ClinicalAssessment Version: 0.1.0
Standards status: Trial-use Maturity Level: 1 Computable Name: ClinicalAssessment
Other Identifiers: OID:2.16.840.1.113883.4.642.5.1351

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.

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.

[%stu-note dstu%] 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.

[%end-note%]

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.

Background and Context

An important background to understanding this resource is the FHIR Confluence page for clinical assessment. 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.

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.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalAssessment 0..* 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
... 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: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... 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): The workflow state of a clinical assessment.
... statusReason 0..1 CodeableConcept Reason for current status
Binding: ClinicalAssessmentStatusReason (example): Codes identifying the reason for the current state of a clinical assessment.
... description Σ 0..1 string Why/how the assessment was performed
... 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(Clinical assessment) 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: ClinicalAssessmentChangePatter (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
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... item 0..1 CodeableReference(Condition | Observation | DocumentReference) What was found
Binding: ConditionProblemDiagnosisCodes (example): Identification of the Condition or diagnosis.
.... basis 0..1 string Which investigations support finding
... prognosis 0..* CodeableReference(RiskAssessment) Estimate of likely outcome
Binding: ClinicalAssessmentPrognosis (example): Prognosis or outlook findings.
... supportingInfo 0..* Reference(Resource) Information supporting the clinical assessment
... note 0..* Annotation Comments made about the ClinicalAssessment

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalAssessment.language Base required All Languages 📍6.0.0-ballot3 FHIR Std.
ClinicalAssessment.status Base required EventStatus 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.statusReason Base example ClinicalAssessment Status Reason 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.changePattern Base example ClinicalAssessment Change Pattern 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.finding.​item Base example Condition/Problem/Diagnosis Codes 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.prognosis Base example Clinical assessment Prognosis 📦6.0.0-ballot3 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalAssessment If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalAssessment 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.trace('id') in %resource.descendants().select(reference | as(uri))) or descendants().where(reference='#' | as(uri)='#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalAssessment 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 ClinicalAssessment If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalAssessment 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())

This structure is derived from DomainResource

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalAssessment 0..* 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): The workflow state of a clinical assessment.
... statusReason 0..1 CodeableConcept Reason for current status
Binding: ClinicalAssessmentStatusReason (example): Codes identifying the reason for the current state of a clinical assessment.
... 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(Clinical assessment) 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: ClinicalAssessmentChangePatter (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: ConditionProblemDiagnosisCodes (example): Identification of the Condition or diagnosis.
.... basis 0..1 string Which investigations support finding
... prognosis 0..* CodeableReference(RiskAssessment) Estimate of likely outcome
Binding: ClinicalAssessmentPrognosis (example): Prognosis or outlook findings.
... supportingInfo 0..* Reference(Resource) Information supporting the clinical assessment
... note 0..* Annotation Comments made about the ClinicalAssessment

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClinicalAssessment.status Base required EventStatus 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.statusReason Base example ClinicalAssessment Status Reason 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.changePattern Base example ClinicalAssessment Change Pattern 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.finding.​item Base example Condition/Problem/Diagnosis Codes 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.prognosis Base example Clinical assessment Prognosis 📦6.0.0-ballot3 FHIR Std.
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalAssessment 0..* 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
... 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: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... 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): The workflow state of a clinical assessment.
... statusReason 0..1 CodeableConcept Reason for current status
Binding: ClinicalAssessmentStatusReason (example): Codes identifying the reason for the current state of a clinical assessment.
... description Σ 0..1 string Why/how the assessment was performed
... 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(Clinical assessment) 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: ClinicalAssessmentChangePatter (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
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... item 0..1 CodeableReference(Condition | Observation | DocumentReference) What was found
Binding: ConditionProblemDiagnosisCodes (example): Identification of the Condition or diagnosis.
.... basis 0..1 string Which investigations support finding
... prognosis 0..* CodeableReference(RiskAssessment) Estimate of likely outcome
Binding: ClinicalAssessmentPrognosis (example): Prognosis or outlook findings.
... supportingInfo 0..* Reference(Resource) Information supporting the clinical assessment
... note 0..* Annotation Comments made about the ClinicalAssessment

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalAssessment.language Base required All Languages 📍6.0.0-ballot3 FHIR Std.
ClinicalAssessment.status Base required EventStatus 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.statusReason Base example ClinicalAssessment Status Reason 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.changePattern Base example ClinicalAssessment Change Pattern 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.finding.​item Base example Condition/Problem/Diagnosis Codes 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.prognosis Base example Clinical assessment Prognosis 📦6.0.0-ballot3 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalAssessment If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalAssessment 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.trace('id') in %resource.descendants().select(reference | as(uri))) or descendants().where(reference='#' | as(uri)='#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalAssessment 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 ClinicalAssessment If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalAssessment 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())

This structure is derived from DomainResource

Summary

Mandatory: 0 element(2 nested mandatory elements)

Maturity: 1

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalAssessment 0..* 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
... 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: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... 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): The workflow state of a clinical assessment.
... statusReason 0..1 CodeableConcept Reason for current status
Binding: ClinicalAssessmentStatusReason (example): Codes identifying the reason for the current state of a clinical assessment.
... description Σ 0..1 string Why/how the assessment was performed
... 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(Clinical assessment) 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: ClinicalAssessmentChangePatter (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
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... item 0..1 CodeableReference(Condition | Observation | DocumentReference) What was found
Binding: ConditionProblemDiagnosisCodes (example): Identification of the Condition or diagnosis.
.... basis 0..1 string Which investigations support finding
... prognosis 0..* CodeableReference(RiskAssessment) Estimate of likely outcome
Binding: ClinicalAssessmentPrognosis (example): Prognosis or outlook findings.
... supportingInfo 0..* Reference(Resource) Information supporting the clinical assessment
... note 0..* Annotation Comments made about the ClinicalAssessment

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalAssessment.language Base required All Languages 📍6.0.0-ballot3 FHIR Std.
ClinicalAssessment.status Base required EventStatus 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.statusReason Base example ClinicalAssessment Status Reason 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.changePattern Base example ClinicalAssessment Change Pattern 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.finding.​item Base example Condition/Problem/Diagnosis Codes 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.prognosis Base example Clinical assessment Prognosis 📦6.0.0-ballot3 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalAssessment If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalAssessment 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.trace('id') in %resource.descendants().select(reference | as(uri))) or descendants().where(reference='#' | as(uri)='#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalAssessment 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 ClinicalAssessment If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalAssessment 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())

Differential View

This structure is derived from DomainResource

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalAssessment 0..* 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): The workflow state of a clinical assessment.
... statusReason 0..1 CodeableConcept Reason for current status
Binding: ClinicalAssessmentStatusReason (example): Codes identifying the reason for the current state of a clinical assessment.
... 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(Clinical assessment) 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: ClinicalAssessmentChangePatter (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: ConditionProblemDiagnosisCodes (example): Identification of the Condition or diagnosis.
.... basis 0..1 string Which investigations support finding
... prognosis 0..* CodeableReference(RiskAssessment) Estimate of likely outcome
Binding: ClinicalAssessmentPrognosis (example): Prognosis or outlook findings.
... supportingInfo 0..* Reference(Resource) Information supporting the clinical assessment
... note 0..* Annotation Comments made about the ClinicalAssessment

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClinicalAssessment.status Base required EventStatus 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.statusReason Base example ClinicalAssessment Status Reason 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.changePattern Base example ClinicalAssessment Change Pattern 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.finding.​item Base example Condition/Problem/Diagnosis Codes 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.prognosis Base example Clinical assessment Prognosis 📦6.0.0-ballot3 FHIR Std.

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalAssessment 0..* 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
... 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: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... 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): The workflow state of a clinical assessment.
... statusReason 0..1 CodeableConcept Reason for current status
Binding: ClinicalAssessmentStatusReason (example): Codes identifying the reason for the current state of a clinical assessment.
... description Σ 0..1 string Why/how the assessment was performed
... 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(Clinical assessment) 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: ClinicalAssessmentChangePatter (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
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... item 0..1 CodeableReference(Condition | Observation | DocumentReference) What was found
Binding: ConditionProblemDiagnosisCodes (example): Identification of the Condition or diagnosis.
.... basis 0..1 string Which investigations support finding
... prognosis 0..* CodeableReference(RiskAssessment) Estimate of likely outcome
Binding: ClinicalAssessmentPrognosis (example): Prognosis or outlook findings.
... supportingInfo 0..* Reference(Resource) Information supporting the clinical assessment
... note 0..* Annotation Comments made about the ClinicalAssessment

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalAssessment.language Base required All Languages 📍6.0.0-ballot3 FHIR Std.
ClinicalAssessment.status Base required EventStatus 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.statusReason Base example ClinicalAssessment Status Reason 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.changePattern Base example ClinicalAssessment Change Pattern 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.finding.​item Base example Condition/Problem/Diagnosis Codes 📦6.0.0-ballot3 FHIR Std.
ClinicalAssessment.prognosis Base example Clinical assessment Prognosis 📦6.0.0-ballot3 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalAssessment If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalAssessment 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.trace('id') in %resource.descendants().select(reference | as(uri))) or descendants().where(reference='#' | as(uri)='#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalAssessment 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 ClinicalAssessment If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalAssessment 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())

This structure is derived from DomainResource

Summary

Mandatory: 0 element(2 nested mandatory elements)

Maturity: 1

 

​Other representations of profile: CSV, Excel, Schematron

Notes:

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.