Introduction and scope
The profile originates from the base resource ClinicalImpression and contains information about the patient’s health status, e.g. vital signs and TOKS-score, information about the reason for hospitalization and clinical examination. The purpose of the profile is to register which examinations have been conducted during the hospitalization of the patient, both for planned chemotherapy sessions and during urgent admissions.
The profile contains six elements: identifier, status, subject, assessor, finding, and note. The element identifier contains a patient ID to ensure a connection to the correct patient. The element status is mandatory and is set to registered. The element subject contains a reference to the profile Patient. The element assessor contains a reference to the profile Practitioner. The element finding is sliced into 21 slices to ensure registration of the results from clinical examinations. Each slice contains a SNOMED CT code. For some slices, the selected SNOMED CT code does not fully cover the registration, but is the closest match. This applies to the slices palpationOfLymph, toksScore, presentIllness, painDuration and painPlacement. The element finding also contains an extension to the extension DateTime. The last element, note, contains information about the patient's anamnesis and is therefore sliced into eight slices.