NHDR Implementation Guide Release 1.0, published by NHDR. 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/PROJ-PHILHEALTH-EA-NHDR/PhilHealth-NHDR-IG-Review/ and changes regularly. See the Directory of published versions
Resource Profile: PH ClinicalImpression
| Official URL: https://nhdr.gov.ph/fhir/StructureDefinition/PH-ClinicalImpression | Version: 0.1.0 | |||
| Standards status: Draft | Computable Name: PH_ClinicalImpression | |||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
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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.
Usages:
- This Profile is not used by any profiles in this Implementation Guide
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
  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 | Group) | Patient or group assessed |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1From the FHIR Standard | |
| ClinicalImpression.investigation.code | example | InvestigationTypehttp://hl7.org/fhir/ValueSet/investigation-setsFrom 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: |
|---|---|---|---|---|
| ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
 implicitRules |
0..0 | |||
| language |
0..0 | |||
| text |
0..0 | |||
| contained |
0..0 | |||
 extension |
0..0 | |||
 modifierExtension |
0..0 | |||
| identifier |
0..0 | |||
| statusReason |
0..0 | |||
| code |
0..0 | |||
| description |
0..0 | |||
| encounter |
0..0 | |||
| effective[x] |
0..0 | |||
| date |
0..0 | |||
| assessor |
0..0 | |||
| previous |
0..0 | |||
| problem |
0..0 | |||
| investigation |
0..0 | |||
| protocol |
0..0 | |||
| summary |
0..0 | |||
 finding |
||||
 id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| itemReference |
0..0 | |||
| basis |
0..0 | |||
| prognosisCodeableConcept |
0..0 | |||
| prognosisReference |
0..0 | |||
| supportingInfo |
0..0 | |||
| note |
0..0 | |||
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| 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 |
| 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 | Group) | Patient or group assessed |
 finding |
0..* | BackboneElement | Possible or likely findings and diagnoses | |
 itemCodeableConcept |
0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1From the FHIR Standard | |
| 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 |
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
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
| 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 | Group) | Patient or group assessed |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1From the FHIR Standard | |
| ClinicalImpression.investigation.code | example | InvestigationTypehttp://hl7.org/fhir/ValueSet/investigation-setsFrom 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: |
|---|---|---|---|---|
| ClinicalImpression |
0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
| implicitRules |
0..0 | |||
| language |
0..0 | |||
| text |
0..0 | |||
| contained |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| identifier |
0..0 | |||
| statusReason |
0..0 | |||
| code |
0..0 | |||
| description |
0..0 | |||
| encounter |
0..0 | |||
| effective[x] |
0..0 | |||
| date |
0..0 | |||
| assessor |
0..0 | |||
| previous |
0..0 | |||
| problem |
0..0 | |||
| investigation |
0..0 | |||
| protocol |
0..0 | |||
| summary |
0..0 | |||
| finding |
||||
| id |
0..0 | |||
| extension |
0..0 | |||
| modifierExtension |
0..0 | |||
| itemReference |
0..0 | |||
| basis |
0..0 | |||
| prognosisCodeableConcept |
0..0 | |||
| prognosisReference |
0..0 | |||
| supportingInfo |
0..0 | |||
| note |
0..0 | |||
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| 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 |
| 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 | Group) | Patient or group assessed |
| finding |
0..* | BackboneElement | Possible or likely findings and diagnoses | |
| itemCodeableConcept |
0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1From the FHIR Standard | |
| 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 |
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
Other representations of profile: CSV, Excel, Schematron