Austrian Patient Summary (R4), published by ELGA GmbH. This guide is not an authorized publication; it is the continuous build for version 0.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7Austria/ELGA-AustrianPatientSummary-R4/ and changes regularly. See the Directory of published versions

• Content
• Detailed Descriptions
• Mappings
• XML
• JSON

Resource Profile: AT APS ClinicalImpression

Das AT APS-Profil für die ClinicalImpression-Ressource berücksichtigt die österreichischen Vorgaben (z.B. Patient).

Usages:

• Use this Profile: AT APS Bundle
• Refer to this Profile: AT APS Composition

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.

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClinicalImpression		0..*	ClinicalImpression	AT APS ClinicalImpression
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(AT APS Patient | Group)	Patient or group assessed
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
ClinicalImpression.status	required	ClinicalImpressionStatus http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 From the FHIR Standard

Constraints

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClinicalImpression		0..*	ClinicalImpression	AT APS ClinicalImpression
subject		1..1	Reference(AT APS Patient | Group)	Patient or group assessed
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClinicalImpression		0..*	ClinicalImpression	AT APS ClinicalImpression
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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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: (example): Codes identifying the reason for the current state of a clinical impression.
code	Σ	0..1	CodeableConcept	Kind of assessment performed Binding Description: (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(AT APS Patient | Group)	Patient or group assessed
encounter	Σ	0..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	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
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

Terminology Bindings

Path	Conformance	ValueSet	URI
ClinicalImpression.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClinicalImpression.status	required	ClinicalImpressionStatus http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 From the FHIR Standard
ClinicalImpression.statusReason	example
ClinicalImpression.code	example
ClinicalImpression.investigation.code	example	InvestigationType http://hl7.org/fhir/ValueSet/investigation-sets From the FHIR Standard
ClinicalImpression.finding.itemCodeableConcept	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code From the FHIR Standard
ClinicalImpression.prognosisCodeableConcept	example	ClinicalImpressionPrognosis http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis From the FHIR Standard

Constraints

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

Summary

Structures

This structure refers to these other structures:

• AT APS Patient (https://fhir.hl7.at/elga/aps/r4/StructureDefinition/at-aps-patient)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClinicalImpression		0..*	ClinicalImpression	AT APS ClinicalImpression
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(AT APS Patient | Group)	Patient or group assessed
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
ClinicalImpression.status	required	ClinicalImpressionStatus http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 From the FHIR Standard

Constraints

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()

Differential View

This structure is derived from ClinicalImpression

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClinicalImpression		0..*	ClinicalImpression	AT APS ClinicalImpression
subject		1..1	Reference(AT APS Patient | Group)	Patient or group assessed
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClinicalImpression		0..*	ClinicalImpression	AT APS ClinicalImpression
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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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: (example): Codes identifying the reason for the current state of a clinical impression.
code	Σ	0..1	CodeableConcept	Kind of assessment performed Binding Description: (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(AT APS Patient | Group)	Patient or group assessed
encounter	Σ	0..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	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
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

Terminology Bindings

Path	Conformance	ValueSet	URI
ClinicalImpression.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClinicalImpression.status	required	ClinicalImpressionStatus http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 From the FHIR Standard
ClinicalImpression.statusReason	example
ClinicalImpression.code	example
ClinicalImpression.investigation.code	example	InvestigationType http://hl7.org/fhir/ValueSet/investigation-sets From the FHIR Standard
ClinicalImpression.finding.itemCodeableConcept	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code From the FHIR Standard
ClinicalImpression.prognosisCodeableConcept	example	ClinicalImpressionPrognosis http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis From the FHIR Standard

Constraints

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

Summary

Structures

This structure refers to these other structures:

• AT APS Patient (https://fhir.hl7.at/elga/aps/r4/StructureDefinition/at-aps-patient)

Other representations of profile: CSV, Excel, Schematron