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Organization FHIR Core /
Project Core StructureDefinitions - STU3
ClinicalImpression
Base StructureDefinition for ClinicalImpression Resource
- type Profile on ClinicalImpression
- FHIR STU3
- status Maturity Level 0
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versionnone
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- Could not resolve: http://hl7.org/fhir/StructureDefinition/Identifier
- Could not resolve: http://hl7.org/fhir/StructureDefinition/code
- Could not resolve: http://hl7.org/fhir/StructureDefinition/CodeableConcept
- Could not resolve: http://hl7.org/fhir/StructureDefinition/string
- Could not resolve: http://hl7.org/fhir/StructureDefinition/Reference
- Could not resolve: http://hl7.org/fhir/StructureDefinition/Element
- Could not resolve: http://hl7.org/fhir/StructureDefinition/dateTime
- Could not resolve: http://hl7.org/fhir/StructureDefinition/BackboneElement
- Could not resolve: http://hl7.org/fhir/StructureDefinition/uri
- Could not resolve: http://hl7.org/fhir/StructureDefinition/Annotation
| ClinicalImpression | I | DomainResource | Element idClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient DefinitionA 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.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idClinicalImpression.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. id |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idClinicalImpression.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource. Meta |
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idClinicalImpression.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation. uri |
| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idClinicalImpression.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). code BindingA human language. ?? (extensible) | |
| text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idClinicalImpression.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later. Narrative Mappings
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idClinicalImpression.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idClinicalImpression.extension Additional Content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Mappings
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| modifierExtension | ?! | 0..* | Extension | There are no (further) constraints on this element Element idClinicalImpression.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Mappings
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| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idClinicalImpression.identifier Business identifier DefinitionA unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored on. Identifier Mappings
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idClinicalImpression.status draft | completed | entered-in-error DefinitionIdentifies the workflow status of the assessment. This element is labeled as a modifier because the status contains the code entered-in-error that marks the clinical impression as not currently valid. code BindingThe workflow state of a clinical impression. ?? (required)Mappings
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| code | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClinicalImpression.code Kind of assessment performed Alternate namestype DefinitionCategorizes the type of clinical assessment performed. This is present as a place-holder only and may be removed based on feedback/work group opinion. CodeableConcept BindingIdentifies categories of clinical impressions. This is a place-holder only. It may be removed (unbound) (example)Mappings
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| description | Σ | 0..1 | string | There are no (further) constraints on this element Element idClinicalImpression.description Why/how the assessment was performed DefinitionA summary of the context and/or cause of the assessment - why / where was it performed, and what patient events/status prompted it. string |
| subject | Σ | 1..1 | Reference(Patient | Group) | There are no (further) constraints on this element Element idClinicalImpression.subject Patient or group assessed DefinitionThe patient or group of individuals assessed as part of this record. Group is typically for veterinary and/or public health purposes.
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| context | Σ | 0..1 | Reference(Encounter | EpisodeOfCare) | There are no (further) constraints on this element Element idClinicalImpression.context Encounter or Episode created from Alternate namesencounter DefinitionThe encounter or episode of care this impression was created as part of. Reference(Encounter | EpisodeOfCare) Mappings
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| effective[x] | Σ | 0..1 | There are no (further) constraints on this element Element idClinicalImpression.effective[x] Time of assessment DefinitionThe point in time or period over which the subject was assessed. This SHOULD be accurate to at least the minute, though some assessments only have a known date.
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| effectiveDateTime | dateTime | There are no (further) constraints on this element Data type dateTime | ||
| effectivePeriod | Period | There are no (further) constraints on this element Data type Period | ||
| date | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idClinicalImpression.date When the assessment was documented DefinitionIndicates when the documentation of the assessment was complete. dateTime Mappings
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| assessor | Σ | 0..1 | Reference(Practitioner) | There are no (further) constraints on this element Element idClinicalImpression.assessor The clinician performing the assessment DefinitionThe clinician performing the assessment. Reference(Practitioner) Mappings
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| previous | 0..1 | Reference(ClinicalImpression) | There are no (further) constraints on this element Element idClinicalImpression.previous Reference to last assessment DefinitionA reference to the last assesment that was conducted bon 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. It is always likely that multiple previous assessments exist for a patient. The point of quoting a previous assessment is that this assessment is relative to it (see resolved). Reference(ClinicalImpression) | |
| problem | Σ | 0..* | Reference(Condition | AllergyIntolerance) | There are no (further) constraints on this element Element idClinicalImpression.problem Relevant impressions of patient state DefinitionThis a list of the relevant problems/conditions for a patient. e.g. The patient is a pregnant, and cardiac congestive failure, Adenocarcinoma, and is allergic to penicillin. Reference(Condition | AllergyIntolerance) Mappings
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| investigation | 0..* | BackboneElement | There are no (further) constraints on this element Element idClinicalImpression.investigation One or more sets of investigations (signs, symptions, etc.) DefinitionOne or more sets of investigations (signs, symptions, etc.). The actual grouping of investigations vary 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. BackboneElement | |
| protocol | 0..* | uri | There are no (further) constraints on this element Element idClinicalImpression.protocol Clinical Protocol followed DefinitionReference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis. uri | |
| summary | 0..1 | string | There are no (further) constraints on this element Element idClinicalImpression.summary Summary of the assessment DefinitionA text summary of the investigations and the diagnosis. string Mappings
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| finding | 0..* | BackboneElement | There are no (further) constraints on this element Element idClinicalImpression.finding Possible or likely findings and diagnoses DefinitionSpecific findings or diagnoses that was considered likely or relevant to ongoing treatment. BackboneElement | |
| prognosisCodeableConcept | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept Estimate of likely outcome DefinitionEstimate of likely outcome. CodeableConcept BindingPrognosis or outlook findings ?? (example)Mappings
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| prognosisReference | 0..* | Reference(RiskAssessment) | There are no (further) constraints on this element Element idClinicalImpression.prognosisReference RiskAssessment expressing likely outcome DefinitionRiskAssessment expressing likely outcome. Reference(RiskAssessment) | |
| action | 0..* | Reference(ReferralRequest | ProcedureRequest | Procedure | MedicationRequest | Appointment) | There are no (further) constraints on this element Element idClinicalImpression.action Action taken as part of assessment procedure DefinitionAction taken as part of assessment procedure. Actions recommended as a result of the impression should not be captured using the 'action' element. Reference(ReferralRequest | ProcedureRequest | Procedure | MedicationRequest | Appointment) | |
| note | 0..* | Annotation | There are no (further) constraints on this element Element idClinicalImpression.note Comments made about the ClinicalImpression DefinitionCommentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear. Don't use this element for content that should more properly appear as one of the specific elements of the impression. Annotation |
Documentation:
https://simplifier.net/coreprofilesstu3/clinicalimpression
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