NHDR Implementation Guide Release 1.0
0.1.0 - ci-build

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/UP-Manila-SILab/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

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 Specification

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: doco
ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
ClinicalImpression.status This element is a modifier element. This element is included in summaries. 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
ClinicalImpression.subject This element is included in summaries. 1..1 Reference(Patient | Group) Patient or group assessed
ClinicalImpression.effective[x] This element is included in summaries. 0..1 dateTime Time of assessment

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: doco
ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
ClinicalImpression.meta
ClinicalImpression.meta.Slices for extension Content/Rules for all slices
ClinicalImpression.meta.Slices for extension.extension:hfRecordedDate 0..1 dateTime The recorded date indicating when the record was uploaded by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
ClinicalImpression.meta.Slices for extension.extension:hfLastUpdated 0..* dateTime The date indicating when the record was last updated by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
ClinicalImpression.meta.lastUpdated 0..1 instant When the resource was uploaded to the NHDR.
ClinicalImpression.implicitRules 0..0 A set of rules under which this content was created
ClinicalImpression.language 0..0 Language of the resource content
ClinicalImpression.contained 0..0 Contained, inline Resources
ClinicalImpression.extension 0..0 Extension
ClinicalImpression.modifierExtension 0..0 Extension
ClinicalImpression.identifier 0..0 Business identifier
ClinicalImpression.statusReason 0..0 Reason for current status
ClinicalImpression.code 0..0 Kind of assessment performed
ClinicalImpression.encounter 0..0 Encounter created as part of
ClinicalImpression.effective[x] 0..1 dateTime Time of assessment
ClinicalImpression.date 0..0 When the assessment was documented
ClinicalImpression.assessor 0..0 The clinician performing the assessment
ClinicalImpression.previous 0..0 Reference to last assessment
ClinicalImpression.problem 0..0 Relevant impressions of patient state
ClinicalImpression.investigation 0..0 One or more sets of investigations (signs, symptoms, etc.)
ClinicalImpression.protocol 0..0 Clinical Protocol followed
ClinicalImpression.summary 0..0 Summary of the assessment
ClinicalImpression.finding
ClinicalImpression.finding.id 0..0 Unique id for inter-element referencing
ClinicalImpression.finding.extension 0..0 Extension
ClinicalImpression.finding.modifierExtension 0..0 Extension
ClinicalImpression.finding.itemReference 0..0 What was found
ClinicalImpression.finding.basis 0..0 Which investigations support finding
ClinicalImpression.prognosisCodeableConcept 0..0 Estimate of likely outcome
ClinicalImpression.prognosisReference 0..0 RiskAssessment expressing likely outcome
ClinicalImpression.supportingInfo 0..0 Information supporting the clinical impression
ClinicalImpression.note 0..0 Comments made about the ClinicalImpression

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: doco
ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
ClinicalImpression.id This element is included in summaries. 0..1 id Logical id of this artifact
ClinicalImpression.meta This element is included in summaries. 0..1 Meta Metadata about the resource
ClinicalImpression.meta.id 0..1 string Unique id for inter-element referencing
ClinicalImpression.meta.Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClinicalImpression.meta.Slices for extension.extension:hfRecordedDate 0..1 dateTime The recorded date indicating when the record was uploaded by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
ClinicalImpression.meta.Slices for extension.extension:hfLastUpdated 0..* dateTime The date indicating when the record was last updated by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
ClinicalImpression.meta.versionId This element is included in summaries. 0..1 id Version specific identifier
ClinicalImpression.meta.lastUpdated This element is included in summaries. 0..1 instant When the resource was uploaded to the NHDR.
ClinicalImpression.meta.source This element is included in summaries. 0..1 uri Identifies where the resource comes from
ClinicalImpression.meta.profile This element is included in summaries. 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
ClinicalImpression.meta.security This element is included in summaries. 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
ClinicalImpression.meta.tag This element is included in summaries. 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
ClinicalImpression.status This element is a modifier element. This element is included in summaries. 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
ClinicalImpression.description This element is included in summaries. 0..1 string Why/how the assessment was performed
ClinicalImpression.subject This element is included in summaries. 1..1 Reference(Patient | Group) Patient or group assessed
ClinicalImpression.effective[x] This element is included in summaries. 0..1 dateTime Time of assessment
ClinicalImpression.finding 0..* BackboneElement Possible or likely findings and diagnoses
ClinicalImpression.finding.itemCodeableConcept 0..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.meta.​security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
ClinicalImpression.meta.​tag Base example Common Tags 📍4.0.1 FHIR Std.
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

Prohibited: 26 elements

Extensions

This structure refers to these extensions:

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: doco
ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
ClinicalImpression.status This element is a modifier element. This element is included in summaries. 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
ClinicalImpression.subject This element is included in summaries. 1..1 Reference(Patient | Group) Patient or group assessed
ClinicalImpression.effective[x] This element is included in summaries. 0..1 dateTime Time of assessment

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: doco
ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
ClinicalImpression.meta
ClinicalImpression.meta.Slices for extension Content/Rules for all slices
ClinicalImpression.meta.Slices for extension.extension:hfRecordedDate 0..1 dateTime The recorded date indicating when the record was uploaded by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
ClinicalImpression.meta.Slices for extension.extension:hfLastUpdated 0..* dateTime The date indicating when the record was last updated by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
ClinicalImpression.meta.lastUpdated 0..1 instant When the resource was uploaded to the NHDR.
ClinicalImpression.implicitRules 0..0 A set of rules under which this content was created
ClinicalImpression.language 0..0 Language of the resource content
ClinicalImpression.text 0..0 Text summary of the resource, for human interpretation
ClinicalImpression.contained 0..0 Contained, inline Resources
ClinicalImpression.extension 0..0 Extension
ClinicalImpression.modifierExtension 0..0 Extension
ClinicalImpression.identifier 0..0 Business identifier
ClinicalImpression.statusReason 0..0 Reason for current status
ClinicalImpression.code 0..0 Kind of assessment performed
ClinicalImpression.encounter 0..0 Encounter created as part of
ClinicalImpression.effective[x] 0..1 dateTime Time of assessment
ClinicalImpression.date 0..0 When the assessment was documented
ClinicalImpression.assessor 0..0 The clinician performing the assessment
ClinicalImpression.previous 0..0 Reference to last assessment
ClinicalImpression.problem 0..0 Relevant impressions of patient state
ClinicalImpression.investigation 0..0 One or more sets of investigations (signs, symptoms, etc.)
ClinicalImpression.protocol 0..0 Clinical Protocol followed
ClinicalImpression.summary 0..0 Summary of the assessment
ClinicalImpression.finding
ClinicalImpression.finding.id 0..0 Unique id for inter-element referencing
ClinicalImpression.finding.extension 0..0 Extension
ClinicalImpression.finding.modifierExtension 0..0 Extension
ClinicalImpression.finding.itemReference 0..0 What was found
ClinicalImpression.finding.basis 0..0 Which investigations support finding
ClinicalImpression.prognosisCodeableConcept 0..0 Estimate of likely outcome
ClinicalImpression.prognosisReference 0..0 RiskAssessment expressing likely outcome
ClinicalImpression.supportingInfo 0..0 Information supporting the clinical impression
ClinicalImpression.note 0..0 Comments made about the ClinicalImpression

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: doco
ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
ClinicalImpression.id This element is included in summaries. 0..1 id Logical id of this artifact
ClinicalImpression.meta This element is included in summaries. 0..1 Meta Metadata about the resource
ClinicalImpression.meta.id 0..1 string Unique id for inter-element referencing
ClinicalImpression.meta.Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClinicalImpression.meta.Slices for extension.extension:hfRecordedDate 0..1 dateTime The recorded date indicating when the record was uploaded by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFRecordedDate
ClinicalImpression.meta.Slices for extension.extension:hfLastUpdated 0..* dateTime The date indicating when the record was last updated by the health facility.
URL: https://nhdr.gov.ph/fhir/StructureDefinition/HFLastUpdated
ClinicalImpression.meta.versionId This element is included in summaries. 0..1 id Version specific identifier
ClinicalImpression.meta.lastUpdated This element is included in summaries. 0..1 instant When the resource was uploaded to the NHDR.
ClinicalImpression.meta.source This element is included in summaries. 0..1 uri Identifies where the resource comes from
ClinicalImpression.meta.profile This element is included in summaries. 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
ClinicalImpression.meta.security This element is included in summaries. 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
ClinicalImpression.meta.tag This element is included in summaries. 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
ClinicalImpression.status This element is a modifier element. This element is included in summaries. 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
ClinicalImpression.description This element is included in summaries. 0..1 string Why/how the assessment was performed
ClinicalImpression.subject This element is included in summaries. 1..1 Reference(Patient | Group) Patient or group assessed
ClinicalImpression.effective[x] This element is included in summaries. 0..1 dateTime Time of assessment
ClinicalImpression.finding 0..* BackboneElement Possible or likely findings and diagnoses
ClinicalImpression.finding.itemCodeableConcept 0..1 CodeableConcept What was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.meta.​security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
ClinicalImpression.meta.​tag Base example Common Tags 📍4.0.1 FHIR Std.
ClinicalImpression.status Base required Clinical Impression Status 📍4.0.1 FHIR Std.
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

Prohibited: 26 elements

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel, Schematron