FHIR New Zealand Patient Summary IG
0.3.0 - ci-build
FHIR New Zealand Patient Summary IG, published by Health NZ | Te Whatu Ora. This guide is not an authorized publication; it is the continuous build for version 0.3.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/tewhatuora/fhir-nzps/ and changes regularly. See the Directory of published versions
Official URL: https://standards.digital.health.nz/fhir/StructureDefinition/nzps-clinicalimpression | Version: 0.3.0 | |||
Active as of 2024-11-22 | Computable Name: NZPSClinicalImpression |
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.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClinicalImpression
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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. |
subject | Σ | 1..1 | Reference(Patient | Group) | Patient or group assessed |
Documentation for this format |
Path | Conformance | ValueSet | URI |
ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 from the FHIR Standard |
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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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.
| |||||
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(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 |
Path | Conformance | ValueSet | URI | |||
ClinicalImpression.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 from the FHIR Standard | ||||
ClinicalImpression.statusReason | example | |||||
ClinicalImpression.code | example | |||||
ClinicalImpression.investigation.code | example | InvestigationTypehttp://hl7.org/fhir/ValueSet/investigation-sets from the FHIR Standard | ||||
ClinicalImpression.finding.itemCodeableConcept | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
ClinicalImpression.prognosisCodeableConcept | example | ClinicalImpressionPrognosishttp://hl7.org/fhir/ValueSet/clinicalimpression-prognosis from the FHIR Standard |
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
Differential View
This structure is derived from ClinicalImpression
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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. |
subject | Σ | 1..1 | Reference(Patient | Group) | Patient or group assessed |
Documentation for this format |
Path | Conformance | ValueSet | URI |
ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 from the FHIR Standard |
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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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.
| |||||
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(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 |
Path | Conformance | ValueSet | URI | |||
ClinicalImpression.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
ClinicalImpression.status | required | ClinicalImpressionStatushttp://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1 from the FHIR Standard | ||||
ClinicalImpression.statusReason | example | |||||
ClinicalImpression.code | example | |||||
ClinicalImpression.investigation.code | example | InvestigationTypehttp://hl7.org/fhir/ValueSet/investigation-sets from the FHIR Standard | ||||
ClinicalImpression.finding.itemCodeableConcept | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
ClinicalImpression.prognosisCodeableConcept | example | ClinicalImpressionPrognosishttp://hl7.org/fhir/ValueSet/clinicalimpression-prognosis from the FHIR Standard |
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