Profile: CareConnect-GPC-ClinicalImpression-1
ClinicalImpression | |||
Short | A clinical assessment performed when planning treatments and management strategies for a patient | ||
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..* | ||
Constraints |
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Mappings |
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ClinicalImpression.id | |||
Short | Logical id of this artifact | ||
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 | id | ||
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 | |||
Short | Metadata about the resource | ||
Definition | The 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. | ||
Cardinality | 0..1 | ||
Type | Meta | ||
Summary | True | ||
ClinicalImpression.implicitRules | |||
Short | A set of rules under which this content was created | ||
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. | ||
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. 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. | ||
ClinicalImpression.language | |||
Short | Language of the resource content | ||
Definition | The base language in which the resource is written. | ||
Cardinality | 0..1 | ||
Type | code | ||
Binding | A human language. Binding extensions
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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). | ||
ClinicalImpression.text | |||
Short | Text summary of the resource, for human interpretation | ||
Definition | A 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. | ||
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 in formation is added later. | ||
Conditions | The cardinality or value of this element may be affected by these constraints: dom-1 | ||
Mappings |
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ClinicalImpression.contained | |||
Short | Contained, inline Resources | ||
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. | ||
Mappings |
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ClinicalImpression.extension | |||
Short | Additional Content defined by implementations | ||
Definition | May 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. | ||
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. | ||
Mappings |
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ClinicalImpression.modifierExtension | |||
Short | Extensions that cannot be ignored | ||
Definition | May 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. | ||
Cardinality | 0..* | ||
Type | Extension | ||
Modifier | True | ||
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. | ||
Mappings |
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ClinicalImpression.identifier | |||
Short | Business identifier | ||
Definition | A unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored on. | ||
Cardinality | 0..* | ||
Type | Identifier | ||
Summary | True | ||
Mappings |
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ClinicalImpression.identifier.id | |||
Short | xml:id (or equivalent in JSON) | ||
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.identifier.extension | |||
Short | Additional Content defined by implementations | ||
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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. | ||
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) Extensions are always sliced by (at least) url | ||
Mappings |
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ClinicalImpression.identifier.use | |||
Short | usual | official | temp | secondary (If known) | ||
Definition | The purpose of this identifier. | ||
Cardinality | 0..1 | ||
Type | code | ||
Binding | Identifies the purpose for this identifier, if known . | ||
Modifier | True | ||
Summary | True | ||
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. | ||
Comments | This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. | ||
Mappings |
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ClinicalImpression.identifier.type | |||
Short | Description of identifier | ||
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose. | ||
Cardinality | 0..1 | ||
Type | CodeableConcept | ||
Binding | A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||
Summary | True | ||
Requirements | Allows users to make use of identifiers when the identifier system is not known. | ||
Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. | ||
Mappings |
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ClinicalImpression.identifier.system | |||
Short | The namespace for the identifier value | ||
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique. | ||
Cardinality | 0..1 | ||
Type | uri | ||
Summary | True | ||
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. | ||
Examples | Generalhttp://www.acme.com/identifiers/patient | ||
Mappings |
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ClinicalImpression.identifier.value | |||
Short | The value that is unique | ||
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system. | ||
Cardinality | 0..1 | ||
Type | string | ||
Summary | True | ||
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. | ||
Examples | General123456 | ||
Mappings |
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ClinicalImpression.identifier.period | |||
Short | Time period when id is/was valid for use | ||
Definition | Time period during which identifier is/was valid for use. | ||
Cardinality | 0..1 | ||
Type | Period | ||
Summary | True | ||
Mappings |
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ClinicalImpression.identifier.assigner | |||
Short | Organization that issued id (may be just text) | ||
Definition | Organization that issued/manages the identifier. | ||
Cardinality | 0..1 | ||
Type | Reference(CareConnect-GPC-Organization-1) | ||
Summary | True | ||
Comments | The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. | ||
Mappings |
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ClinicalImpression.status | |||
Short | draft | completed | entered-in-error | ||
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. | ||
Mappings |
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ClinicalImpression.code | |||
Short | Kind of assessment performed | ||
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. | ||
Mappings |
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ClinicalImpression.description | |||
Short | Why/how the assessment was performed | ||
Definition | A summary of the context and/or cause of the assessment - why / where was it performed, and what patient events/status prompted it. | ||
Cardinality | 0..1 | ||
Type | string | ||
Summary | True | ||
ClinicalImpression.subject | |||
Short | Patient or group assessed | ||
Definition | The patient or group of individuals assessed as part of this record. | ||
Cardinality | 1..1 | ||
Type | Reference(Group | CareConnect-GPC-Patient-1) | ||
Summary | True | ||
Requirements | Group is typically for veterinary and/or public health purposes. | ||
Mappings |
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ClinicalImpression.context | |||
Short | Encounter or Episode created from | ||
Definition | The encounter or episode of care this impression was created as part of. | ||
Cardinality | 0..1 | ||
Type | Reference(EpisodeOfCare | CareConnect-GPC-Encounter-1) | ||
Summary | True | ||
Alias | encounter | ||
Mappings |
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ClinicalImpression.effective[x] | |||
Short | Time of assessment | ||
Definition | The point in time or period over which the subject was assessed. | ||
Cardinality | 0..1 | ||
Type | dateTime, Period | ||
Summary | True | ||
Comments | This SHOULD be accurate to at least the minute, though some assessments only have a known date. | ||
Mappings |
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ClinicalImpression.date | |||
Short | When the assessment was documented | ||
Definition | Indicates when the documentation of the assessment was complete. | ||
Cardinality | 0..1 | ||
Type | dateTime | ||
Summary | True | ||
Mappings |
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ClinicalImpression.assessor | |||
Short | The clinician performing the assessment | ||
Definition | The clinician performing the assessment. | ||
Cardinality | 0..1 | ||
Type | Reference(CareConnect-GPC-Practitioner-1) | ||
Summary | True | ||
Mappings |
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ClinicalImpression.previous | |||
Short | Reference to last assessment | ||
Definition | A 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. | ||
Cardinality | 0..1 | ||
Type | Reference(CareConnect-GPC-ClinicalImpression-1) | ||
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). | ||
ClinicalImpression.problem | |||
Short | Relevant impressions of patient state | ||
Definition | This a list of the relevant problems/conditions for a patient. | ||
Cardinality | 0..* | ||
Type | Reference(CareConnect-GPC-Condition-1 | CareConnect-GPC-AllergyIntolerance-1) | ||
Summary | True | ||
Comments | e.g. The patient is a pregnant, and cardiac congestive failure, Adenocarcinoma, and is allergic to penicillin. | ||
Mappings |
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ClinicalImpression.investigation | |||
Short | One or more sets of investigations (signs, symptions, etc.) | ||
Definition | One 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. | ||
Cardinality | 0..* | ||
Type | BackboneElement | ||
Constraints |
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ClinicalImpression.investigation.id | |||
Short | xml:id (or equivalent in JSON) | ||
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 | |||
Short | Additional Content defined by implementations | ||
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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. | ||
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. | ||
Mappings |
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ClinicalImpression.investigation.modifierExtension | |||
Short | Extensions that cannot be ignored | ||
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 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. | ||
Cardinality | 0..* | ||
Type | Extension | ||
Modifier | True | ||
Summary | True | ||
Alias | extensions, user content, modifiers | ||
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. | ||
Mappings |
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ClinicalImpression.investigation.code | |||
Short | A name/code for the set | ||
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|nutitirional) history may be used. | ||
Cardinality | 1..1 | ||
Type | CodeableConcept | ||
Binding | A name/code for a set of investigations. | ||
ClinicalImpression.investigation.item | |||
Short | Record of a specific investigation | ||
Definition | A record of a specific investigation that was undertaken. | ||
Cardinality | 0..* | ||
Type | Reference(QuestionnaireResponse | FamilyMemberHistory | RiskAssessment | ImagingStudy | CareConnect-GPC-Observation-1 | CareConnect-GPC-DiagnosticReport-1) | ||
Comments | Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used. | ||
Mappings |
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ClinicalImpression.protocol | |||
Short | Clinical Protocol followed | ||
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 | ||
ClinicalImpression.summary | |||
Short | Summary of the assessment | ||
Definition | A text summary of the investigations and the diagnosis. | ||
Cardinality | 1..1 | ||
Type | string | ||
Mappings |
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ClinicalImpression.finding | |||
Short | Possible or likely findings and diagnoses | ||
Definition | Specific findings or diagnoses that was considered likely or relevant to ongoing treatment. | ||
Cardinality | 0..* | ||
Type | BackboneElement | ||
Constraints |
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ClinicalImpression.finding.id | |||
Short | xml:id (or equivalent in JSON) | ||
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 | |||
Short | Additional Content defined by implementations | ||
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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. | ||
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. | ||
Mappings |
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ClinicalImpression.finding.modifierExtension | |||
Short | Extensions that cannot be ignored | ||
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 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. | ||
Cardinality | 0..* | ||
Type | Extension | ||
Modifier | True | ||
Summary | True | ||
Alias | extensions, user content, modifiers | ||
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. | ||
Mappings |
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ClinicalImpression.finding.item[x] | |||
Short | What was found | ||
Definition | Specific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditions. | ||
Cardinality | 1..1 | ||
Type | Reference(CareConnect-GPC-ProblemHeader-Condition-1 | CareConnect-GPC-Observation-1), CodeableConcept | ||
Binding | Identification of the Condition or diagnosis. | ||
Mappings |
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ClinicalImpression.finding.basis | |||
Short | Which investigations support finding | ||
Definition | Which investigations support finding or diagnosis. | ||
Cardinality | 0..1 | ||
Type | string | ||
ClinicalImpression.prognosisCodeableConcept | |||
Short | Estimate of likely outcome | ||
Definition | Estimate of likely outcome. | ||
Cardinality | 0..* | ||
Type | CodeableConcept | ||
Binding | Prognosis or outlook findings | ||
Mappings |
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ClinicalImpression.prognosisReference | |||
Short | RiskAssessment expressing likely outcome | ||
Definition | RiskAssessment expressing likely outcome. | ||
Cardinality | 0..* | ||
Type | Reference(RiskAssessment) | ||
ClinicalImpression.action | |||
Short | Action taken as part of assessment procedure | ||
Definition | Action taken as part of assessment procedure. | ||
Cardinality | 0..* | ||
Type | Reference(Procedure | CareConnect-GPC-ReferralRequest-1 | CareConnect-GPC-ProcedureRequest-1 | CareConnect-GPC-MedicationRequest-1 | CareConnect-GPC-Appointment-1) | ||
Comments | Actions recommended as a result of the impression should not be captured using the 'action' element. | ||
ClinicalImpression.note | |||
Short | Comments made about the ClinicalImpression | ||
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. |
Related links
Data model element usage
Element | Use | CareConnect (STU3) | UK Core (R4) |
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identifier | |||
status | |||
code | |||
description | |||
subject | |||
context | |||
effective[x] | |||
date | |||
assessor | |||
previous | |||
problem | |||
investigation | |||
protocol | |||
summary | |||
finding | |||
prognosisCodableConcept | |||
prognosisReference | |||
action | |||
note |
identifier
Usage
MandatoryGuidance
Theidentifier
element MUST be populated with a globally unique and persistent identifier (that is, it doesn’t change between requests and therefore stored with the source data). This MUST be scoped by a provider specific namespace for the identifier.Where consuming systems are integrating data from this resource to their local system, they MUST also persist this identifier at the same time.Example
<identifier> <system value="https://tools.ietf.org/html/rfc4122" /> <value value="653c0790-a509-4eed-99f3-f42f3683cf2e" /> </identifier>
status
Usage
OptionalGuidance
The status of the clinical impressione.g. draft | completed | entered-in-error.The overall status.Example
<status> <code value="completed" /> <display value="completed" /> </status>
code
Usage
OptionalGuidance
Categorizes the type of clinical assessment performed.Example
<code> <coding> <display value="Transfer-degraded drug allergy" /> <code value="196461000000101" /> <system value="http://snomed.info/sct" /> <snomedCT> <url value="https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid" /> <extension> <valueId value="294801000000114" /> <descriptionId value="294801000000114" /> <descriptionDisplay value="Transfer-degraded drug allergy (record artifact)" /> </extesion> </snomedCT> </coding> <text value="Allergy to paracetemol" /> </code>
description
Usage
OptionalGuidance
The brief description of the assessment. Why/how the assessment was performed.Example
<description> <display value="Hearing checkup appointment" /> </description>
subject
Usage
OptionalGuidance
The patient or group of individuals assessed as part of this record.Reference(Group | CareConnect-GPC-Patient-1)Example
<subject> <reference value="patient-00112339" /> </subject>
context
Usage
OptionalGuidance
The encounter or episode of care this impression was created as part of.Example
<context> <reference value="encounter-0012345" /> </context>
effective[x]
Usage
OptionalGuidance
The point in time or period over which the subject was assessed.Example
<effectiveDateTime value="2022-12-05T10:09:00+00:00" />
date
Usage
OptionalGuidance
Indicates when the documentation of the assessment was complete.Example
<date value="2022-10-18T14:06:00Z" />
assessor
Usage
OptionalGuidance
Short description
The clinician performing the assessmentProfile: CareConnect-GPC-Practitioner-1Example
<practitioner> <actor> <reference value="practitioner-9093012" /> </actor> </practitioner>
previous
Usage
OptionalGuidance
Short description
A 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.Reference(CareConnect-GPC-ClinicalImpression-1)Example
<previous <reference value="ClinicalImpression-9093012" /> </previous>
problem
Usage
OptionalDefinitionThis a list of the relevant problems/conditions for a patient.Reference(CareConnect-GPC-Condition-1 | CareConnect-GPC-AllergyIntolerance-1)<problem> <reference value="Condition-9093012" /> </problem>
investigation
Usage
OptionalGuidance
Structured assessment name e.g. New York Heart Failure, Glasgow Coma scale, Activities of Daily Living (ADL) etc.Example
---
protocol
Usage
OptionalGuidance
Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.Example
<protocol> <url value="http://example.org/xds/mhd/Binary/07a6483f-732b-461e-86b6-edb665c45510" /> </protocol>
summary
Usage
OptionalGuidance
A text summary of the investigations and the diagnosis.Example
<summary> "Summary notes" </summary>
finding
finding
Usage
OptionalGuidance
Specific findings or diagnoses that was considered likely or relevant to ongoing treatment..Example
<finding> <item> <concept> <coding> <system value="http://hl7.org/fhir/sid/icd-9"/> <code value="850.0"/> </coding> </concept> </item> </finding>
prognosisCodableConcept
Usage
OptionalGuidance
Estimate of likely outcome.Example
<code> <coding> <system value="http://snomed.info/sct" /> <code value="196461000000101" /> <display value="Transfer-degraded drug allergy" /> </coding> <text value="Ongoing physiotherapy should wield positive results" /> </code>
prognosisReference
Usage
OptionalGuidance
RiskAssessment expressing likely outcomeExample
<context> <reference value="riskassessment-0012345" /> </context>
action
Usage
OptionalGuidance
Action taken as part of assessment procedure..Reference(Procedure | CareConnect-GPC-ReferralRequest-1 | CareConnect-GPC-ProcedureRequest-1 | CareConnect-GPC-MedicationRequest-1 | CareConnect-GPC-Appointment-1)Example
<context> <reference value="procedure-0012345" /> </context>
note
Usage
OptionalGuidance
Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear.Example
<note> <author> <reference value="practitioner-948392" /> </author> <time value="2022-10-13T16:59:00Z" /> <text> Free text... R4 of the FHIR standard supports GitHub Flavoured Markdown (GFM). </text> </note>