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9.8 Resource ClinicalImpression - Content

Patient Care Work Group Maturity Level : 0   Draft Trial Use Security Category : Patient Compartments : Encounter , Patient , Practitioner

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.

Performing a clinical assessment is a fundamental part of a clinician's workflow, performed repeatedly throughout the day. In spite of this - or perhaps, because of it - there is wide variance in how clinical impressions are recorded. Some clinical assessments simply result in an impression recorded as a single text note in the patient 'record' (e.g. "Progress satisfactory, continue with treatment"), while others are associated with careful, detailed record keeping of the evidence gathered and the reasoning leading to a differential diagnosis, and there is a continuum between these. This resource is intended to be used to cover all these use cases.

The assessment is intimately linked to the process of care. It may occur in the context of a care plan, and it very often results in a new (or revised) care plan. Normally. Normally, clinical assessments are part of an ongoing process of care, and the patient will be re-assessed repeatedly. For this reason, the clinical impression can explicit explicitly reference both care plans (preceding and resulting) and reference a previous impression that this impression follows on from. follows.

An impression is a clinical summation of information and/or an opinion formed, which is the outcome of the clinical assessment process. The ClinicalImpression may lead to a statement of a Condition about a patient.

In FHIR, an assessment is typically an instrument or tool used to collect information about a patient.

STU Trial-Use Note: Unlike many other resources, there is little prior art with regard to exchanging records of clinical assessments. For this reason, this resource should be regarded as particularly prone to ongoing revision. In terms of scope and usage, the Patient Care workgroup wishes to draw the attention of reviewers and implementers to the following issues:

  • When is an existing clinical impression revised, rather than a new one created (that references the existing one)? How does that affect the status? what's the interplay between the status of the diagnosis and the status of the impression? (e.g. for a 'provisional' impression, which bit is provisional?)
  • This structure doesn't differentiate between a working and a final diagnosis. Given an answer to the previous question, should it?
  • Further clarify around the relationship between care plan and impression is needed. Both answers to the previous questions and ongoing discussions around revisions to the care plan will influence the design of clinical impression
  • Should prognosis be represented, and if so, how much structure should it have?
  • Should an impression reference other impressions that are related? (how related?)
  • Investigations - the specification needs a good value set for the code for the group, and will be considering the name "investigations" further

Feedback is welcome here .

ClinicalImpression is the equivalent of the "A" (assessment) in the SOAP note format originally described by Lawrence Weed, MD. It is the outcome of the clinical assessment process. The ClinicalImpression may lead to a statement of a Condition about a patient. There is another related clinical concept often called an "assessment": assessment Tools such as Apgar (also known as "Assessment Scales"). This is not what the ClinicalImpression resource is about; assessment tools such as Apgar are represented as Observations , and Questionnaires may be used to help generate these. Clinical Impressions may refer to these assessment tools as one of the investigations that was performed during the assessment process.

An important background to understanding this resource is the FHIR wiki Confluence page for clinical assessment . In particular, the storyboards there drove the design of the resource, and will be the basis for all examples created.

PLANNED CHANGE:

ClinicalImpression is one of the Event resources in the FHIR Workflow specification. As such, it is expected to be adjusted to align with the Event workflow pattern which will involve adding a number of additional data elements and potentially renaming a few elements. Any concerns about performing such alignment are welcome as ballot comments and/or tracker items.

This resource is referenced by condition itself and Condition .

This resource implements the Event pattern.

Structure

investigation 0..* BackboneElement One or more sets of investigations (signs, symptoms, etc.) code 1..1 CodeableConcept A name/code for the set Investigation Type ( Example ) item 0..* Reference ( Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media ) Record of a specific investigation
Name Flags Card. Type Description & Constraints doco
. . ClinicalImpression D TU DomainResource A clinical assessment performed when planning treatments and management strategies for a patient
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier Business identifier
. . . status ?! Σ 1..1 code draft in-progress | completed | entered-in-error
ClinicalImpressionStatus Clinical Impression Status ( Required )
. . . statusReason 0..1 CodeableConcept Reason for current status
... code Σ 0..1 CodeableConcept Kind of assessment performed
. . . description Σ 0..1 string Why/how the assessment was performed
. . . subject Σ 1..1 Reference ( Patient | Group ) Patient or group assessed
. . . context encounter Σ 0..1 Reference ( Encounter | EpisodeOfCare ) The Encounter or Episode during which this ClinicalImpression was created from
. . . effective[x] Σ 0..1 Time of assessment
. . . . effectiveDateTime dateTime
. . . . effectivePeriod Period
. . . date Σ 0..1 dateTime When the assessment was documented
. . . assessor performer 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
. . . protocol 0..* uri Clinical Protocol followed
. . . summary 0..1 string Summary of the assessment
. . . finding 0..* BackboneElement Possible or likely findings and diagnoses
. . . . itemCodeableConcept 0..1 CodeableConcept What was found
Condition/Problem/Diagnosis Codes ( Example )
. . . . 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
Clinical Impression Prognosis ( Example )
. . . prognosisReference 0..* Reference ( RiskAssessment ) RiskAssessment expressing likely outcome
. . . action supportingInfo 0..* Reference ( ServiceRequest | Procedure | MedicationRequest | Appointment Any ) Action taken as part of assessment procedure Information supporting the clinical impression
. . . note 0..* Annotation Comments made about the ClinicalImpression

doco Documentation for this format

UML Diagram ( Legend )

ClinicalImpression ( DomainResource ) Business identifiers assigned to this clinical impression by the performer or other systems which remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] Identifies the workflow status of the assessment (this element modifies the meaning of other elements) status : code [1..1] « The workflow state of a clinical impression. (Strength=Required) ClinicalImpressionStatus ! » Captures the reason for the current state of the ClinicalImpression statusReason : CodeableConcept [0..1] Categorizes the type of clinical assessment performed code : CodeableConcept [0..1] A summary of the context and/or cause of the assessment - why / where was it was performed, and what patient events/status prompted it description : string [0..1] The patient or group of individuals assessed as part of this record subject : Reference [1..1] « Patient | Group » The encounter or episode of care Encounter during which this impression ClinicalImpression was created as part or to which the creation of this record is tightly associated context encounter : Reference [0..1] « Encounter | EpisodeOfCare » The point in time or period over which the subject was assessed effective[x] : Type [0..1] « dateTime | Period » Indicates when the documentation of the assessment was complete date : dateTime [0..1] The clinician performing the assessment assessor performer : Reference [0..1] « Practitioner | PractitionerRole » A reference to the last assessment that was conducted on this patient. Assessments are often/usually ongoing in nature; a care provider (practitioner or team) will make new assessments on an ongoing basis as new data arises or the patient's conditions changes previous : Reference [0..1] « ClinicalImpression » This a A list of the relevant problems/conditions for a patient problem : Reference [0..*] « Condition | AllergyIntolerance » Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis protocol : uri [0..*] A text summary of the investigations and the diagnosis summary : string [0..1] Estimate of likely outcome prognosisCodeableConcept : CodeableConcept [0..*] « Prognosis or outlook findings findings. (Strength=Example) Clinical Impression Prognosis ClinicalImpressionPrognosis ?? » RiskAssessment expressing likely outcome prognosisReference : Reference [0..*] « RiskAssessment » Action taken as part of assessment procedure Information supporting the clinical impression, which can contain investigation results action supportingInfo : Reference [0..*] « ServiceRequest | Procedure | MedicationRequest | Appointment Any » Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear note : Annotation [0..*] Investigation A name/code for the group ("set") of investigations. Typically, this will be something like "signs", "symptoms", "clinical", "diagnostic", but the list is not constrained, and others such groups such as (exposure|family|travel|nutritional) history may be used code : CodeableConcept [1..1] « A name/code for a set of investigations. (Strength=Example) Investigation Type ?? » A record of a specific investigation that was undertaken item : Reference [0..*] « Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media » Finding Specific text or code for finding or diagnosis, which may include ruled-out or resolved conditions itemCodeableConcept : CodeableConcept [0..1] « Identification of the Condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis Condition/Problem/DiagnosisCo... ?? » Specific reference for finding or diagnosis, which may include ruled-out or resolved conditions itemReference : Reference [0..1] « Condition | Observation | Media » Which investigations support finding or diagnosis basis : string [0..1] One or more sets of investigations (signs, symptoms, etc.). The actual grouping of investigations varies greatly depending on the type and context of the assessment. These investigations may include data generated during the assessment process, or data previously generated and recorded that is pertinent to the outcomes investigation [0..*] Specific findings or diagnoses that was were considered likely or relevant to ongoing treatment finding [0..*]

XML Template

<ClinicalImpression xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business identifier --></identifier>
 <

 <status value="[code]"/><!-- 1..1 in-progress | completed | entered-in-error -->
 <statusReason><!-- 0..1 CodeableConcept Reason for current status --></statusReason>

 <code><!-- 0..1 CodeableConcept Kind of assessment performed --></code>
 <
 <</subject>
 <</context>

 <description value="[string]"/><!-- 0..1 Why/how the assessment was performed -->
 <subject><!-- 1..1 Reference(Group|Patient) Patient or group assessed --></subject>
 <encounter><!-- 0..1 Reference(Encounter) The Encounter during which this ClinicalImpression was created --></encounter>

 <effective[x]><!-- 0..1 dateTime|Period Time of assessment --></effective[x]>
 <date value="[dateTime]"/><!-- 0..1 When the assessment was documented -->
 <</assessor>

 <performer><!-- 0..1 Reference(Practitioner|PractitionerRole) The clinician performing the assessment --></performer>

 <previous><!-- 0..1 Reference(ClinicalImpression) Reference to last assessment --></previous>
 <</problem>
 <
  <</code>
  <|
    </item>
 </investigation>

 <problem><!-- 0..* Reference(AllergyIntolerance|Condition) Relevant impressions of patient state --></problem>

 <protocol value="[uri]"/><!-- 0..* Clinical Protocol followed -->
 <summary value="[string]"/><!-- 0..1 Summary of the assessment -->
 <

 <finding>  <!-- 0..* Possible or likely findings and diagnoses -->

  <itemCodeableConcept><!-- 0..1 CodeableConcept What was found --></itemCodeableConcept>
  <</itemReference>

  <itemReference><!-- 0..1 Reference(Condition|Media|Observation) What was found --></itemReference>

  <basis value="[string]"/><!-- 0..1 Which investigations support finding -->
 </finding>
 <prognosisCodeableConcept><!-- 0..* CodeableConcept Estimate of likely outcome --></prognosisCodeableConcept>
 <prognosisReference><!-- 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome --></prognosisReference>
 <|
   </action>

 <supportingInfo><!-- 0..* Reference(Any) Information supporting the clinical impression --></supportingInfo>

 <note><!-- 0..* Annotation Comments made about the ClinicalImpression --></note>
</ClinicalImpression>

JSON Template

{doco
  "resourceType" : "ClinicalImpression",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business identifier
  "

  "status" : "<code>", // R!  in-progress | completed | entered-in-error
  "statusReason" : { CodeableConcept }, // Reason for current status

  "code" : { CodeableConcept }, // Kind of assessment performed
  "
  "
  "

  "description" : "<string>", // Why/how the assessment was performed
  "subject" : { Reference(Group|Patient) }, // R!  Patient or group assessed
  "encounter" : { Reference(Encounter) }, // The Encounter during which this ClinicalImpression was created

  // effective[x]: Time of assessment. One of these 2:
  "effectiveDateTime" : "<dateTime>",
  "effectivePeriod" : { Period },
  "date" : "<dateTime>", // When the assessment was documented
  "

  "performer" : { Reference(Practitioner|PractitionerRole) }, // The clinician performing the assessment

  "previous" : { Reference(ClinicalImpression) }, // Reference to last assessment
  "
  "
    "
    "|
    
  }],

  "problem" : [{ Reference(AllergyIntolerance|Condition) }], // Relevant impressions of patient state

  "protocol" : ["<uri>"], // Clinical Protocol followed
  "summary" : "<string>", // Summary of the assessment
  "

  "finding" : [{ // Possible or likely findings and diagnoses

    "itemCodeableConcept" : { CodeableConcept }, // What was found
    "

    "itemReference" : { Reference(Condition|Media|Observation) }, // What was found

    "basis" : "<string>" // Which investigations support finding
  }],
  "prognosisCodeableConcept" : [{ CodeableConcept }], // Estimate of likely outcome
  "prognosisReference" : [{ Reference(RiskAssessment) }], // RiskAssessment expressing likely outcome
  "|
   

  "supportingInfo" : [{ Reference(Any) }], // Information supporting the clinical impression

  "note" : [{ Annotation }] // Comments made about the ClinicalImpression
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:ClinicalImpression;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root
  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClinicalImpression.identifier [ Identifier ], ... ; # 0..* Business identifier
  fhir:

  fhir:ClinicalImpression.status [ code ]; # 1..1 in-progress | completed | entered-in-error
  fhir:ClinicalImpression.statusReason [ CodeableConcept ]; # 0..1 Reason for current status

  fhir:ClinicalImpression.code [ CodeableConcept ]; # 0..1 Kind of assessment performed
  fhir:
  fhir:
  fhir:

  fhir:ClinicalImpression.description [ string ]; # 0..1 Why/how the assessment was performed
  fhir:ClinicalImpression.subject [ Reference(Group|Patient) ]; # 1..1 Patient or group assessed
  fhir:ClinicalImpression.encounter [ Reference(Encounter) ]; # 0..1 The Encounter during which this ClinicalImpression was created

  # ClinicalImpression.effective[x] : 0..1 Time of assessment. One of these 2
    fhir:ClinicalImpression.effectiveDateTime [ dateTime ]
    fhir:ClinicalImpression.effectivePeriod [ Period ]
  fhir:ClinicalImpression.date [ dateTime ]; # 0..1 When the assessment was documented
  fhir:

  fhir:ClinicalImpression.performer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 The clinician performing the assessment

  fhir:ClinicalImpression.previous [ Reference(ClinicalImpression) ]; # 0..1 Reference to last assessment
  fhir:
  fhir:
    fhir:
    fhir:|
  
  ], ...;

  fhir:ClinicalImpression.problem [ Reference(AllergyIntolerance|Condition) ], ... ; # 0..* Relevant impressions of patient state

  fhir:ClinicalImpression.protocol [ uri ], ... ; # 0..* Clinical Protocol followed
  fhir:ClinicalImpression.summary [ string ]; # 0..1 Summary of the assessment
  fhir:

  fhir:ClinicalImpression.finding [ # 0..* Possible or likely findings and diagnoses

    fhir:ClinicalImpression.finding.itemCodeableConcept [ CodeableConcept ]; # 0..1 What was found
    fhir:

    fhir:ClinicalImpression.finding.itemReference [ Reference(Condition|Media|Observation) ]; # 0..1 What was found

    fhir:ClinicalImpression.finding.basis [ string ]; # 0..1 Which investigations support finding
  ], ...;
  fhir:ClinicalImpression.prognosisCodeableConcept [ CodeableConcept ], ... ; # 0..* Estimate of likely outcome
  fhir:ClinicalImpression.prognosisReference [ Reference(RiskAssessment) ], ... ; # 0..* RiskAssessment expressing likely outcome
  fhir:

  fhir:ClinicalImpression.supportingInfo [ Reference(Any) ], ... ; # 0..* Information supporting the clinical impression

  fhir:ClinicalImpression.note [ Annotation ], ... ; # 0..* Comments made about the ClinicalImpression
]

Changes since R3

ClinicalImpression
ClinicalImpression.investigation.item ClinicalImpression.status
  • Type changed Change value set from Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|DiagnosticReport|RiskAssessment|ImagingStudy) http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.0 to Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|DiagnosticReport|RiskAssessment|ImagingStudy|Media) ClinicalImpression.finding.itemCodeableConcept Added Element http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.1.0
ClinicalImpression.finding.itemReference ClinicalImpression.performer
  • Added Element
ClinicalImpression.action ClinicalImpression.assessor
  • Type changed from Reference(ReferralRequest|ProcedureRequest|Procedure|MedicationRequest|Appointment) to Reference(ServiceRequest|Procedure|MedicationRequest|Appointment) deleted
ClinicalImpression.finding.item[x] ClinicalImpression.investigation
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

See R2 <--> R3 <--> R4 Conversion Maps (status = 1 test that all execute ok. 1 fail All tests pass round-trip testing and all r3 resources are valid.). Note: these have note yet been updated to be R3 to R4 valid.)

Structure

investigation 0..* BackboneElement One or more sets of investigations (signs, symptoms, etc.) code 1..1 CodeableConcept A name/code for the set Investigation Type ( Example ) item 0..* Reference ( Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media ) Record of a specific investigation
Name Flags Card. Type Description & Constraints doco
. . ClinicalImpression D TU DomainResource A clinical assessment performed when planning treatments and management strategies for a patient
Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier Business identifier
. . . status ?! Σ 1..1 code draft in-progress | completed | entered-in-error
ClinicalImpressionStatus Clinical Impression Status ( Required )
. . . statusReason 0..1 CodeableConcept Reason for current status
... code Σ 0..1 CodeableConcept Kind of assessment performed
. . . description Σ 0..1 string Why/how the assessment was performed
. . . subject Σ 1..1 Reference ( Patient | Group ) Patient or group assessed
. . . context encounter Σ 0..1 Reference ( Encounter | EpisodeOfCare ) The Encounter or Episode during which this ClinicalImpression was created from
. . . effective[x] Σ 0..1 Time of assessment
. . . . effectiveDateTime dateTime
. . . . effectivePeriod Period
. . . date Σ 0..1 dateTime When the assessment was documented
. . . assessor performer 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
. . . protocol 0..* uri Clinical Protocol followed
. . . summary 0..1 string Summary of the assessment
. . . finding 0..* BackboneElement Possible or likely findings and diagnoses
. . . . itemCodeableConcept 0..1 CodeableConcept What was found
Condition/Problem/Diagnosis Codes ( Example )
. . . . 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
Clinical Impression Prognosis ( Example )
. . . prognosisReference 0..* Reference ( RiskAssessment ) RiskAssessment expressing likely outcome
. . . action supportingInfo 0..* Reference ( ServiceRequest | Procedure | MedicationRequest | Appointment Any ) Action taken as part of assessment procedure Information supporting the clinical impression
. . . note 0..* Annotation Comments made about the ClinicalImpression

doco Documentation for this format

UML Diagram ( Legend )

ClinicalImpression ( DomainResource ) Business identifiers assigned to this clinical impression by the performer or other systems which remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] Identifies the workflow status of the assessment (this element modifies the meaning of other elements) status : code [1..1] « The workflow state of a clinical impression. (Strength=Required) ClinicalImpressionStatus ! » Captures the reason for the current state of the ClinicalImpression statusReason : CodeableConcept [0..1] Categorizes the type of clinical assessment performed code : CodeableConcept [0..1] A summary of the context and/or cause of the assessment - why / where was it was performed, and what patient events/status prompted it description : string [0..1] The patient or group of individuals assessed as part of this record subject : Reference [1..1] « Patient | Group » The encounter or episode of care Encounter during which this impression ClinicalImpression was created as part or to which the creation of this record is tightly associated context encounter : Reference [0..1] « Encounter | EpisodeOfCare » The point in time or period over which the subject was assessed effective[x] : Type [0..1] « dateTime | Period » Indicates when the documentation of the assessment was complete date : dateTime [0..1] The clinician performing the assessment assessor performer : Reference [0..1] « Practitioner | PractitionerRole » A reference to the last assessment that was conducted on this patient. Assessments are often/usually ongoing in nature; a care provider (practitioner or team) will make new assessments on an ongoing basis as new data arises or the patient's conditions changes previous : Reference [0..1] « ClinicalImpression » This a A list of the relevant problems/conditions for a patient problem : Reference [0..*] « Condition | AllergyIntolerance » Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis protocol : uri [0..*] A text summary of the investigations and the diagnosis summary : string [0..1] Estimate of likely outcome prognosisCodeableConcept : CodeableConcept [0..*] « Prognosis or outlook findings findings. (Strength=Example) Clinical Impression Prognosis ClinicalImpressionPrognosis ?? » RiskAssessment expressing likely outcome prognosisReference : Reference [0..*] « RiskAssessment » Action taken as part of assessment procedure Information supporting the clinical impression, which can contain investigation results action supportingInfo : Reference [0..*] « ServiceRequest | Procedure | MedicationRequest | Appointment Any » Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear note : Annotation [0..*] Investigation A name/code for the group ("set") of investigations. Typically, this will be something like "signs", "symptoms", "clinical", "diagnostic", but the list is not constrained, and others such groups such as (exposure|family|travel|nutritional) history may be used code : CodeableConcept [1..1] « A name/code for a set of investigations. (Strength=Example) Investigation Type ?? » A record of a specific investigation that was undertaken item : Reference [0..*] « Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media » Finding Specific text or code for finding or diagnosis, which may include ruled-out or resolved conditions itemCodeableConcept : CodeableConcept [0..1] « Identification of the Condition or diagnosis. (Strength=Example) Condition/Problem/Diagnosis Condition/Problem/DiagnosisCo... ?? » Specific reference for finding or diagnosis, which may include ruled-out or resolved conditions itemReference : Reference [0..1] « Condition | Observation | Media » Which investigations support finding or diagnosis basis : string [0..1] One or more sets of investigations (signs, symptoms, etc.). The actual grouping of investigations varies greatly depending on the type and context of the assessment. These investigations may include data generated during the assessment process, or data previously generated and recorded that is pertinent to the outcomes investigation [0..*] Specific findings or diagnoses that was were considered likely or relevant to ongoing treatment finding [0..*]

XML Template

<ClinicalImpression xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business identifier --></identifier>
 <

 <status value="[code]"/><!-- 1..1 in-progress | completed | entered-in-error -->
 <statusReason><!-- 0..1 CodeableConcept Reason for current status --></statusReason>

 <code><!-- 0..1 CodeableConcept Kind of assessment performed --></code>
 <
 <</subject>
 <</context>

 <description value="[string]"/><!-- 0..1 Why/how the assessment was performed -->
 <subject><!-- 1..1 Reference(Group|Patient) Patient or group assessed --></subject>
 <encounter><!-- 0..1 Reference(Encounter) The Encounter during which this ClinicalImpression was created --></encounter>

 <effective[x]><!-- 0..1 dateTime|Period Time of assessment --></effective[x]>
 <date value="[dateTime]"/><!-- 0..1 When the assessment was documented -->
 <</assessor>

 <performer><!-- 0..1 Reference(Practitioner|PractitionerRole) The clinician performing the assessment --></performer>

 <previous><!-- 0..1 Reference(ClinicalImpression) Reference to last assessment --></previous>
 <</problem>
 <
  <</code>
  <|
    </item>
 </investigation>

 <problem><!-- 0..* Reference(AllergyIntolerance|Condition) Relevant impressions of patient state --></problem>

 <protocol value="[uri]"/><!-- 0..* Clinical Protocol followed -->
 <summary value="[string]"/><!-- 0..1 Summary of the assessment -->
 <

 <finding>  <!-- 0..* Possible or likely findings and diagnoses -->

  <itemCodeableConcept><!-- 0..1 CodeableConcept What was found --></itemCodeableConcept>
  <</itemReference>

  <itemReference><!-- 0..1 Reference(Condition|Media|Observation) What was found --></itemReference>

  <basis value="[string]"/><!-- 0..1 Which investigations support finding -->
 </finding>
 <prognosisCodeableConcept><!-- 0..* CodeableConcept Estimate of likely outcome --></prognosisCodeableConcept>
 <prognosisReference><!-- 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome --></prognosisReference>
 <|
   </action>

 <supportingInfo><!-- 0..* Reference(Any) Information supporting the clinical impression --></supportingInfo>

 <note><!-- 0..* Annotation Comments made about the ClinicalImpression --></note>
</ClinicalImpression>

JSON Template

{doco
  "resourceType" : "ClinicalImpression",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business identifier
  "

  "status" : "<code>", // R!  in-progress | completed | entered-in-error
  "statusReason" : { CodeableConcept }, // Reason for current status

  "code" : { CodeableConcept }, // Kind of assessment performed
  "
  "
  "

  "description" : "<string>", // Why/how the assessment was performed
  "subject" : { Reference(Group|Patient) }, // R!  Patient or group assessed
  "encounter" : { Reference(Encounter) }, // The Encounter during which this ClinicalImpression was created

  // effective[x]: Time of assessment. One of these 2:
  "effectiveDateTime" : "<dateTime>",
  "effectivePeriod" : { Period },
  "date" : "<dateTime>", // When the assessment was documented
  "

  "performer" : { Reference(Practitioner|PractitionerRole) }, // The clinician performing the assessment

  "previous" : { Reference(ClinicalImpression) }, // Reference to last assessment
  "
  "
    "
    "|
    
  }],

  "problem" : [{ Reference(AllergyIntolerance|Condition) }], // Relevant impressions of patient state

  "protocol" : ["<uri>"], // Clinical Protocol followed
  "summary" : "<string>", // Summary of the assessment
  "

  "finding" : [{ // Possible or likely findings and diagnoses

    "itemCodeableConcept" : { CodeableConcept }, // What was found
    "

    "itemReference" : { Reference(Condition|Media|Observation) }, // What was found

    "basis" : "<string>" // Which investigations support finding
  }],
  "prognosisCodeableConcept" : [{ CodeableConcept }], // Estimate of likely outcome
  "prognosisReference" : [{ Reference(RiskAssessment) }], // RiskAssessment expressing likely outcome
  "|
   

  "supportingInfo" : [{ Reference(Any) }], // Information supporting the clinical impression

  "note" : [{ Annotation }] // Comments made about the ClinicalImpression
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco
[ a fhir:ClinicalImpression;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root
  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClinicalImpression.identifier [ Identifier ], ... ; # 0..* Business identifier
  fhir:

  fhir:ClinicalImpression.status [ code ]; # 1..1 in-progress | completed | entered-in-error
  fhir:ClinicalImpression.statusReason [ CodeableConcept ]; # 0..1 Reason for current status

  fhir:ClinicalImpression.code [ CodeableConcept ]; # 0..1 Kind of assessment performed
  fhir:
  fhir:
  fhir:

  fhir:ClinicalImpression.description [ string ]; # 0..1 Why/how the assessment was performed
  fhir:ClinicalImpression.subject [ Reference(Group|Patient) ]; # 1..1 Patient or group assessed
  fhir:ClinicalImpression.encounter [ Reference(Encounter) ]; # 0..1 The Encounter during which this ClinicalImpression was created

  # ClinicalImpression.effective[x] : 0..1 Time of assessment. One of these 2
    fhir:ClinicalImpression.effectiveDateTime [ dateTime ]
    fhir:ClinicalImpression.effectivePeriod [ Period ]
  fhir:ClinicalImpression.date [ dateTime ]; # 0..1 When the assessment was documented
  fhir:

  fhir:ClinicalImpression.performer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 The clinician performing the assessment

  fhir:ClinicalImpression.previous [ Reference(ClinicalImpression) ]; # 0..1 Reference to last assessment
  fhir:
  fhir:
    fhir:
    fhir:|
  
  ], ...;

  fhir:ClinicalImpression.problem [ Reference(AllergyIntolerance|Condition) ], ... ; # 0..* Relevant impressions of patient state

  fhir:ClinicalImpression.protocol [ uri ], ... ; # 0..* Clinical Protocol followed
  fhir:ClinicalImpression.summary [ string ]; # 0..1 Summary of the assessment
  fhir:

  fhir:ClinicalImpression.finding [ # 0..* Possible or likely findings and diagnoses

    fhir:ClinicalImpression.finding.itemCodeableConcept [ CodeableConcept ]; # 0..1 What was found
    fhir:

    fhir:ClinicalImpression.finding.itemReference [ Reference(Condition|Media|Observation) ]; # 0..1 What was found

    fhir:ClinicalImpression.finding.basis [ string ]; # 0..1 Which investigations support finding
  ], ...;
  fhir:ClinicalImpression.prognosisCodeableConcept [ CodeableConcept ], ... ; # 0..* Estimate of likely outcome
  fhir:ClinicalImpression.prognosisReference [ Reference(RiskAssessment) ], ... ; # 0..* RiskAssessment expressing likely outcome
  fhir:

  fhir:ClinicalImpression.supportingInfo [ Reference(Any) ], ... ; # 0..* Information supporting the clinical impression

  fhir:ClinicalImpression.note [ Annotation ], ... ; # 0..* Comments made about the ClinicalImpression
]

Changes since DSTU2 Release 3

ClinicalImpression
ClinicalImpression.investigation.item ClinicalImpression.status
  • Type changed Change value set from Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|DiagnosticReport|RiskAssessment|ImagingStudy) http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.0 to Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|DiagnosticReport|RiskAssessment|ImagingStudy|Media) ClinicalImpression.finding.itemCodeableConcept Added Element http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.1.0
ClinicalImpression.finding.itemReference ClinicalImpression.performer
  • Added Element
ClinicalImpression.action ClinicalImpression.assessor
  • Type changed from Reference(ReferralRequest|ProcedureRequest|Procedure|MedicationRequest|Appointment) to Reference(ServiceRequest|Procedure|MedicationRequest|Appointment) deleted
ClinicalImpression.finding.item[x] ClinicalImpression.investigation
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

See R2 <--> R3 <--> R4 Conversion Maps (status = 1 test that all execute ok. 1 fail All tests pass round-trip testing and all r3 resources are valid.). Note: these have note yet been updated to be R3 to R4 valid.)

 

Alternate See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions , the spreadsheet version & the dependency analysis a

ClinicalImpression.investigation.code A name/code for a set of investigations. Example Investigation Type
Path Definition Type Reference
ClinicalImpression.status The workflow state of a clinical impression. Required ClinicalImpressionStatus
ClinicalImpression.statusReason Codes identifying the reason for the current state of a clinical impression. Unknown No details provided yet
ClinicalImpression.code Identifies categories of clinical impressions. This is a place-holder only. It may be removed removed. Unknown No details provided yet
ClinicalImpression.finding.itemCodeableConcept Identification of the Condition or diagnosis. Example Condition/Problem/Diagnosis Codes Condition/Problem/DiagnosisCodes
ClinicalImpression.prognosisCodeableConcept Prognosis or outlook findings findings. Example Clinical Impression Prognosis ClinicalImpressionPrognosis

A known issue exists with circular references between Condition and ClinicalImpression, which is due to the low maturity level of ClinicalImpression. The Patient Care work group intends to address this issue when ClinicalImpression is considered substantially complete and ready for implementation.

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
action date reference date Action taken as part of When the assessment procedure ClinicalImpression.action ( Appointment , MedicationRequest , Procedure , ServiceRequest ) was documented assessor ClinicalImpression.date reference The clinician performing the assessment ClinicalImpression.assessor ( Practitioner 17 Resources )
context encounter reference The Encounter or Episode during which this ClinicalImpression was created from ClinicalImpression.context ClinicalImpression.encounter
( EpisodeOfCare , Encounter )
date date When the assessment was documented ClinicalImpression.date 17 Resources finding-code token What was found ClinicalImpression.finding.itemCodeableConcept
finding-ref reference What was found ClinicalImpression.finding.itemReference
( Condition , Observation , Media )
identifier token Business identifier ClinicalImpression.identifier
investigation patient reference Record of a specific investigation Patient or group assessed ClinicalImpression.investigation.item ClinicalImpression.subject.where(resolve() is Patient)
( RiskAssessment , FamilyMemberHistory , Observation , Media , DiagnosticReport , ImagingStudy , QuestionnaireResponse Patient )
33 Resources
patient performer reference Patient or group assessed The clinician performing the assessment ClinicalImpression.subject ClinicalImpression.performer
( Patient Practitioner , PractitionerRole )
29 Resources
previous reference Reference to last assessment ClinicalImpression.previous
( ClinicalImpression )
problem reference Relevant impressions of patient state ClinicalImpression.problem
( Condition , AllergyIntolerance )
status token draft in-progress | completed | entered-in-error ClinicalImpression.status
subject reference Patient or group assessed ClinicalImpression.subject
( Group , Patient )
supporting-info reference Information supporting the clinical impression ClinicalImpression.supportingInfo
(Any)