ClinicalImpression
Defines the ID Core constraints and extension on the 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.
Usage
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, 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 explicitly reference both care plans (preceding and resulting) and reference a previous impression that this impression 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.
URL
Type | URL |
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Canonical | https://fhir.kemkes.go.id/r4/StructureDefinition/ClinicalImpression |
Structure
Snapshot
ClinicalImpression | I | DomainResource | |
id | Σ | 0..1 | string |
meta | Σ | 0..1 | Meta |
implicitRules | Σ ?! | 0..1 | uri |
language | 0..1 | codeBinding | |
text | 0..1 | Narrative | |
contained | 0..* | Resource | |
identifier | Σ | 0..* | Identifier |
status | Σ ?! | 1..1 | codeBinding |
statusReason | 0..1 | CodeableConcept | |
code | Σ | 0..1 | CodeableConcept |
description | Σ | 0..1 | string |
subject | Σ I | 1..1 | Reference(Patient | https://fhir.kemkes.go.id/r4/StructureDefinition/Group) |
encounter | Σ I | 1..1 | Reference(Encounter) |
effective[x] | Σ | 0..1 | |
effectiveDateTime | dateTime | ||
effectivePeriod | Period | ||
date | Σ | 0..1 | dateTime |
assessor | Σ I | 0..1 | Reference(Practitioner | PractitionerRole) |
previous | I | 0..1 | Reference(ClinicalImpression) |
problem | Σ I | 0..* | Reference(Condition | AllergyIntolerance) |
investigation | 0..* | BackboneElement | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
code | 1..1 | CodeableConcept | |
item | I | 0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | https://fhir.kemkes.go.id/r4/StructureDefinition/RiskAssessment | ImagingStudy | https://fhir.kemkes.go.id/r4/StructureDefinition/Media) |
protocol | 0..* | uri | |
summary | 0..1 | string | |
finding | 0..* | BackboneElement | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
itemCodeableConcept | 0..1 | CodeableConcept | |
itemReference | I | 0..1 | Reference(Condition | Observation | https://fhir.kemkes.go.id/r4/StructureDefinition/Media) |
basis | 0..1 | string | |
prognosisCodeableConcept | 1..* | CodeableConcept | |
prognosisReference | I | 0..* | Reference(https://fhir.kemkes.go.id/r4/StructureDefinition/RiskAssessment) |
supportingInfo | I | 0..* | Reference(Resource) |
note | 0..* | Annotation |
Examples
Dictionary
ClinicalImpression | |
Definition | 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. |
Cardinality | 0...* |
Invariants |
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Mappings |
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ClinicalImpression.id | |
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. |
Cardinality | 0...1 |
Type | string |
Summary | True |
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
ClinicalImpression.meta | |
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. |
Cardinality | 0...1 |
Type | Meta |
Summary | True |
Invariants |
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Mappings |
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ClinicalImpression.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Cardinality | 0...1 |
Type | uri |
Modifier | True |
Summary | True |
Comments | 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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Invariants |
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Mappings |
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ClinicalImpression.language | |
Definition | The base language in which the resource is written. |
Cardinality | 0...1 |
Type | code |
Binding | A human language. |
Comments | 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). |
Invariants |
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Mappings |
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ClinicalImpression.text | |
Definition | A human-readable narrative that contains a summary of the resource and can 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. |
Cardinality | 0...1 |
Type | Narrative |
Alias | narrative, html, xhtml, display |
Comments | 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 information is added later. |
Invariants |
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ClinicalImpression.contained | |
Definition | These 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. |
Cardinality | 0...* |
Type | Resource |
Alias | inline resources, anonymous resources, contained resources |
Comments | 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. |
Mappings |
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ClinicalImpression.identifier | |
Definition | 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. |
Cardinality | 0...* |
Type | Identifier |
Summary | True |
Requirements | Allows identification of the clinical impression as it is known by various participating systems and in a way that remains consistent across servers. |
Comments | This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. |
Invariants |
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Mappings |
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ClinicalImpression.status | |
Definition | Identifies the workflow status of the assessment. |
Cardinality | 1...1 |
Type | code |
Binding | The workflow state of a clinical impression. |
Modifier | True |
Summary | True |
Comments | 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. |
Invariants |
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Mappings |
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ClinicalImpression.statusReason | |
Definition | Captures the reason for the current state of the ClinicalImpression. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | Codes identifying the reason for the current state of a clinical impression. |
Alias | Suspended Reason, Cancelled Reason |
Comments | This is generally only used for "exception" statuses such as "not-done", "suspended" or "cancelled". [distinct reason codes for different statuses can be enforced using invariants if they are universal bindings]. |
Invariants |
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Mappings |
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ClinicalImpression.code | |
Definition | Categorizes the type of clinical assessment performed. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | Identifies categories of clinical impressions. This is a place-holder only. It may be removed. |
Summary | True |
Alias | type |
Comments | This is present as a place-holder only and may be removed based on feedback/work group opinion. |
Invariants |
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ClinicalImpression.description | |
Definition | A summary of the context and/or cause of the assessment - why / where it was performed, and what patient events/status prompted it. |
Cardinality | 0...1 |
Type | string |
Summary | True |
Comments | Note that FHIR strings SHALL NOT exceed 1MB in size |
Invariants |
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Mappings |
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ClinicalImpression.subject | |
Definition | The patient or group of individuals assessed as part of this record. |
Cardinality | 1...1 |
Type | Reference(Patient | https://fhir.kemkes.go.id/r4/StructureDefinition/Group) |
Summary | True |
Requirements | Group is typically for veterinary and/or public health purposes. |
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. |
Invariants |
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Mappings |
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ClinicalImpression.encounter | |
Definition | The Encounter during which this ClinicalImpression was created or to which the creation of this record is tightly associated. |
Cardinality | 1...1 |
Type | Reference(Encounter) |
Summary | True |
Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. |
Invariants |
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ClinicalImpression.effective[x] | |
Definition | The point in time or period over which the subject was assessed. |
Cardinality | 0...1 |
Type | dateTime |
Summary | True |
Comments | This SHOULD be accurate to at least the minute, though some assessments only have a known date. |
Invariants |
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Mappings |
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ClinicalImpression.date | |
Definition | Indicates when the documentation of the assessment was complete. |
Cardinality | 0...1 |
Type | dateTime |
Summary | True |
Invariants |
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Mappings |
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ClinicalImpression.assessor | |
Definition | The clinician performing the assessment. |
Cardinality | 0...1 |
Type | Reference(Practitioner | PractitionerRole) |
Summary | True |
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. |
Invariants |
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Mappings |
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ClinicalImpression.previous | |
Definition | 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. |
Cardinality | 0...1 |
Type | Reference(ClinicalImpression) |
Comments | 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). |
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Mappings |
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ClinicalImpression.problem | |
Definition | A list of the relevant problems/conditions for a patient. |
Cardinality | 0...* |
Type | Reference(Condition | AllergyIntolerance) |
Summary | True |
Comments | e.g. The patient is a pregnant, has congestive heart failure, has an Adenocarcinoma, and is allergic to penicillin. |
Invariants |
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Mappings |
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ClinicalImpression.investigation | |
Definition | 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. |
Cardinality | 0...* |
Type | BackboneElement |
Invariants |
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Mappings |
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ClinicalImpression.investigation.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Cardinality | 0...1 |
Type | string |
Mappings |
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ClinicalImpression.investigation.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, user content |
Comments | 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. |
Slicing | Unordered, Open, by url(Value) |
Invariants |
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Mappings |
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ClinicalImpression.investigation.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Cardinality | 0...* |
Type | Extension |
Modifier | True |
Summary | True |
Alias | extensions, user content, modifiers |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Comments | 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. |
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Mappings |
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ClinicalImpression.investigation.code | |
Definition | 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. |
Cardinality | 1...1 |
Type | CodeableConcept |
Binding | A name/code for a set of investigations. |
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. |
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Mappings |
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ClinicalImpression.investigation.item | |
Definition | A record of a specific investigation that was undertaken. |
Cardinality | 0...* |
Type | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | https://fhir.kemkes.go.id/r4/StructureDefinition/RiskAssessment | ImagingStudy | https://fhir.kemkes.go.id/r4/StructureDefinition/Media) |
Comments | Most investigations are observations of one kind or another but some other specific types of data collection resources can also be used. |
Invariants |
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ClinicalImpression.protocol | |
Definition | Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis. |
Cardinality | 0...* |
Type | uri |
Comments | see http://en.wikipedia.org/wiki/Uniform_resource_identifier |
Invariants |
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Mappings |
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ClinicalImpression.summary | |
Definition | A text summary of the investigations and the diagnosis. |
Cardinality | 0...1 |
Type | string |
Comments | Note that FHIR strings SHALL NOT exceed 1MB in size |
Invariants |
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ClinicalImpression.finding | |
Definition | Specific findings or diagnoses that were considered likely or relevant to ongoing treatment. |
Cardinality | 0...* |
Type | BackboneElement |
Invariants |
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Mappings |
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ClinicalImpression.finding.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Cardinality | 0...1 |
Type | string |
Mappings |
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ClinicalImpression.finding.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, user content |
Comments | 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. |
Slicing | Unordered, Open, by url(Value) |
Invariants |
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Mappings |
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ClinicalImpression.finding.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Cardinality | 0...* |
Type | Extension |
Modifier | True |
Summary | True |
Alias | extensions, user content, modifiers |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Comments | 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. |
Invariants |
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Mappings |
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ClinicalImpression.finding.itemCodeableConcept | |
Definition | Specific text or code for finding or diagnosis, which may include ruled-out or resolved conditions. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | Identification of the Condition or diagnosis. |
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. |
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Mappings |
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ClinicalImpression.finding.itemReference | |
Definition | Specific reference for finding or diagnosis, which may include ruled-out or resolved conditions. |
Cardinality | 0...1 |
Type | Reference(Condition | Observation | https://fhir.kemkes.go.id/r4/StructureDefinition/Media) |
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. |
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ClinicalImpression.finding.basis | |
Definition | Which investigations support finding or diagnosis. |
Cardinality | 0...1 |
Type | string |
Comments | Note that FHIR strings SHALL NOT exceed 1MB in size |
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ClinicalImpression.prognosisCodeableConcept | |
Definition | Estimate of likely outcome. |
Cardinality | 1...* |
Type | CodeableConcept |
Binding | Prognosis or outlook findings. |
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. |
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ClinicalImpression.prognosisReference | |
Definition | RiskAssessment expressing likely outcome. |
Cardinality | 0...* |
Type | Reference(https://fhir.kemkes.go.id/r4/StructureDefinition/RiskAssessment) |
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. |
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ClinicalImpression.supportingInfo | |
Definition | Information supporting the clinical impression. |
Cardinality | 0...* |
Type | Reference(Resource) |
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. |
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Mappings |
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ClinicalImpression.note | |
Definition | Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear. |
Cardinality | 0...* |
Type | Annotation |
Comments | Don't use this element for content that should more properly appear as one of the specific elements of the impression. |
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