HL7 FHIR Implementation Guide: Transversal Clinical Core
1.0.1 - STU1 Belgium flag

HL7 FHIR Implementation Guide: Transversal Clinical Core, published by eHealth Platform. This guide is not an authorized publication; it is the continuous build for version 1.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-be/core-clinical/ and changes regularly. See the Directory of published versions

Resource Profile: BeClinicalImpression

Official URL: https://www.ehealth.fgov.be/standards/fhir/core-clinical/StructureDefinition/BeClinicalImpression Version: 1.0.1
Active as of 2024-09-15 Computable Name: BeClinicalImpression

Usage:

  • This Resource 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.

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... subject 1..1 Reference(BePatient | Group) Patient or group assessed
... assessor 0..1 Reference(BePractitioner | BePractitionerRole) The clinician performing the assessment

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

... assessor Σ 0..1 Reference(BePractitioner | BePractitionerRole) The clinician performing the assessment

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClinicalImpression.statusrequiredClinicalImpressionStatus
http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClinicalImpressionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClinicalImpressionIf 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-4errorClinicalImpressionIf 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-5errorClinicalImpressionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClinicalImpressionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

Additional BindingsPurpose
AllLanguages Max Binding
... 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(BePatient | 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(BePractitioner | BePractitionerRole) 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClinicalImpression.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClinicalImpression.statusrequiredClinicalImpressionStatus
http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1
from the FHIR Standard
ClinicalImpression.statusReasonexample
ClinicalImpression.codeexample
ClinicalImpression.investigation.codeexampleInvestigationType
http://hl7.org/fhir/ValueSet/investigation-sets
from the FHIR Standard
ClinicalImpression.finding.itemCodeableConceptexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
ClinicalImpression.prognosisCodeableConceptexampleClinicalImpressionPrognosis
http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClinicalImpressionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClinicalImpressionIf 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-4errorClinicalImpressionIf 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-5errorClinicalImpressionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClinicalImpressionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... subject 1..1 Reference(BePatient | Group) Patient or group assessed
... assessor 0..1 Reference(BePractitioner | BePractitionerRole) The clinician performing the assessment

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

... assessor Σ 0..1 Reference(BePractitioner | BePractitionerRole) The clinician performing the assessment

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClinicalImpression.statusrequiredClinicalImpressionStatus
http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClinicalImpressionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClinicalImpressionIf 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-4errorClinicalImpressionIf 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-5errorClinicalImpressionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClinicalImpressionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

Additional BindingsPurpose
AllLanguages Max Binding
... 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(BePatient | 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(BePractitioner | BePractitionerRole) 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClinicalImpression.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClinicalImpression.statusrequiredClinicalImpressionStatus
http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1
from the FHIR Standard
ClinicalImpression.statusReasonexample
ClinicalImpression.codeexample
ClinicalImpression.investigation.codeexampleInvestigationType
http://hl7.org/fhir/ValueSet/investigation-sets
from the FHIR Standard
ClinicalImpression.finding.itemCodeableConceptexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
ClinicalImpression.prognosisCodeableConceptexampleClinicalImpressionPrognosis
http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClinicalImpressionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClinicalImpressionIf 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-4errorClinicalImpressionIf 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-5errorClinicalImpressionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClinicalImpressionA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron