| EOL-Prognosis-ClinicalImpression-1 (ClinicalImpression) | C | | ClinicalImpression | There are no (further) constraints on this element Element idClinicalImpression Short descriptionA 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.
ClinicalImpression Constraints- dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty() - dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative
contained.text.empty() - dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() - dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
contained.where(('#'+id in %resource.descendants().reference).not()).empty()
Mappings- rim: Entity. Role, or Act
- v2: Partial mapping for problem evaluation
- w5: clinical.general
|
| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idClinicalImpression.id Short descriptionLogical 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 ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idClinicalImpression.meta Short descriptionMetadata 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 ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idClinicalImpression.implicitRules Short descriptionA 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 ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| language | | 0..1 | codeBinding | There are no (further) constraints on this element Element idClinicalImpression.language Short descriptionLanguage 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. Common Languages (extensible) Binding extensionsConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| text | C | 0..1 | Narrative | There are no (further) constraints on this element Element idClinicalImpression.text Short descriptionText 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 ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, dom-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- rim: N/A
- rim: Act.text?
|
| contained | | 0..* | Resource | There are no (further) constraints on this element Element idClinicalImpression.contained Short descriptionContained, 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.
Resource Mappings- rim: Entity. Role, or Act
- rim: N/A
|
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClinicalImpression.extension Short descriptionAdditional 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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| awarenessOfDecision | C | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element idClinicalImpression.extension:awarenessOfDecision Short descriptionOptional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources.
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.
Extension(CodeableConcept) Extension URLhttps://fhir.nhs.uk/STU3/StructureDefinition/Extension-EOL-AwarenessOfDecision-1 ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClinicalImpression.modifierExtension Short descriptionExtensions 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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idClinicalImpression.identifier Short descriptionBusiness identifier DefinitionA unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored on.
Identifier ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
- rim: II - see see identifier pattern at http://wiki.hl7.org/index.php?title=Common_Design_Patterns#Identifier_Pattern for relevant discussion. The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
- servd: Identifier
- v2: PID-3
- w5: id
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClinicalImpression.identifier.id Short descriptionxml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Note that FHIR strings may not exceed 1MB in size
string ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClinicalImpression.identifier.extension Short descriptionAdditional 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 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.
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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| use | Σ ?! | 0..0 | codeBinding | There are no (further) constraints on this element Element idClinicalImpression.identifier.use Short descriptionusual | official | temp | secondary (If known) DefinitionThe purpose of this identifier.
Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
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.
code BindingIdentifies the purpose for this identifier, if known . IdentifierUse (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- v2: N/A
- rim: Role.code or implied by context
|
| type | Σ | 0..0 | CodeableConceptBinding | There are no (further) constraints on this element Element idClinicalImpression.identifier.type Short descriptionDescription of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
Allows users to make use of identifiers when the identifier system is not known.
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.
CodeableConcept BindingA coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- v2: CX.5
- rim: Role.code or implied by context
|
| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idClinicalImpression.identifier.system Short descriptionThe namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique.
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.
see http://en.wikipedia.org/wiki/Uniform_resource_identifier
uri ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Examples
Generalhttp://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the Identifier.value itself is a full uri Mappings- rim: n/a
- v2: CX.4 / EI-2-4
- rim: II.root or Role.id.root
- servd: ./IdentifierType
|
| value | Σ | 1..1 | string | There are no (further) constraints on this element Element idClinicalImpression.identifier.value Short descriptionThe value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system.
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.
string ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Examples
General123456 Mappings- rim: n/a
- v2: CX.1 / EI.1
- rim: II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
- servd: ./Value
|
| period | Σ C | 0..0 | Period | There are no (further) constraints on this element Element idClinicalImpression.identifier.period Short descriptionTime period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use.
This is not a duration - that's a measure of time (a separate type), but a duration that occurs at a fixed value of time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). If duration is required, specify the type as Interval|Duration.
Period ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - per-1: If present, start SHALL have a lower value than end
start.empty() or end.empty() or (start <= end)
Mappings- rim: n/a
- v2: DR
- rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
- v2: CX.7 + CX.8
- rim: Role.effectiveTime or implied by context
- servd: ./StartDate and ./EndDate
|
| assigner | Σ C | 0..0 | Reference(Organization) | There are no (further) constraints on this element Element idClinicalImpression.identifier.assigner Short descriptionOrganization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier.
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.
Reference(Organization) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2: CX.4 / (CX.4,CX.9,CX.10)
- rim: II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
- servd: ./IdentifierIssuingAuthority
|
| status | Σ ?! | 1..1 | codeBindingFixed Value | There are no (further) constraints on this element Element idClinicalImpression.status Short descriptiondraft | 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. ClinicalImpressionStatus (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Fixed valuecompleted Mappings- rim: n/a
- v2: PRB-14
- w5: status
|
| code | Σ | 0..0 | CodeableConcept | There are no (further) constraints on this element Element idClinicalImpression.code Short descriptionKind 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) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- w5: what
|
| description | Σ | 0..1 | string | There are no (further) constraints on this element Element idClinicalImpression.description Short descriptionWhy/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.
Note that FHIR strings may not exceed 1MB in size
string ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| subject | Σ C | 1..1 | Reference(https://fhir.hl7.org.uk/STU3/StructureDefinition/EOL-Patient-1) | There are no (further) constraints on this element Element idClinicalImpression.subject Short descriptionPatient 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.
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.
Reference(https://fhir.hl7.org.uk/STU3/StructureDefinition/EOL-Patient-1) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2: PID-3
- w5: who.focus
|
| context | Σ C | 0..0 | Reference(Encounter | EpisodeOfCare) | There are no (further) constraints on this element Element idClinicalImpression.context Short descriptionEncounter or Episode created from Alternate namesencounter DefinitionThe encounter or episode of care this impression was created as part of.
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.
Reference(Encounter | EpisodeOfCare) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- w5: context
|
| effective[x] | Σ | 0..0 | | There are no (further) constraints on this element Element idClinicalImpression.effective[x] Short descriptionTime 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.
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- v2: PRB-2
- w5: when.done
|
| date | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idClinicalImpression.date Short descriptionDate of Prognosis DefinitionIndicates when the documentation of the assessment was complete.
dateTime ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- w5: when.recorded
|
| assessor | Σ C | 1..1 | Reference(CareConnect-Practitioner-1) | There are no (further) constraints on this element Element idClinicalImpression.assessor Short descriptionThe clinician performing the assessment DefinitionThe clinician performing the assessment.
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.
Reference(CareConnect-Practitioner-1) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2: ROL-4
- w5: who.author
|
| previous | C | 0..0 | Reference(ClinicalImpression) | There are no (further) constraints on this element Element idClinicalImpression.previous Short descriptionReference 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) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
|
| problem | Σ C | 0..0 | Reference(AllergyIntolerance | Condition) | There are no (further) constraints on this element Element idClinicalImpression.problem Short descriptionRelevant 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(AllergyIntolerance | Condition) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- v2: PRB-3 / IAM-7
- w5: why
|
| investigation | | 0..0 | BackboneElement | There are no (further) constraints on this element Element idClinicalImpression.investigation Short descriptionOne 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 ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| protocol | | 0..0 | uri | There are no (further) constraints on this element Element idClinicalImpression.protocol Short descriptionClinical 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.
see http://en.wikipedia.org/wiki/Uniform_resource_identifier
uri ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| summary | | 0..0 | string | There are no (further) constraints on this element Element idClinicalImpression.summary Short descriptionSummary of the assessment DefinitionA text summary of the investigations and the diagnosis.
Note that FHIR strings may not exceed 1MB in size
string ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| finding | | 0..0 | BackboneElement | There are no (further) constraints on this element Element idClinicalImpression.finding Short descriptionPossible or likely findings and diagnoses DefinitionSpecific findings or diagnoses that was considered likely or relevant to ongoing treatment.
BackboneElement ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| prognosisCodeableConcept | | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept Short descriptionEstimate of likely outcome DefinitionEstimate of likely outcome.
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.
CodeableConcept BindingPrognosis or outlook findings EOL Prognosis Code (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- v2: PRB-22
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept.id Short descriptionxml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Note that FHIR strings may not exceed 1MB in size
string ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept.extension Short descriptionAdditional 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 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.
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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| coding | Σ | 0..1 | Coding | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept.coding Short descriptionCode defined by a terminology system DefinitionA reference to a code defined by a terminology system.
Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Coding ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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| id | | 0..1 | string | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept.coding.id Short descriptionxml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Note that FHIR strings may not exceed 1MB in size
string ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept.coding.extension Short descriptionAdditional 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 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.
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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept.coding.system Short descriptionIdentity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code.
Need to be unambiguous about the source of the definition of the symbol.
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
uri ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Fixed valuehttp://snomed.info/sct Mappings- rim: n/a
- v2: C*E.3
- rim: ./codeSystem
- orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
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| version | Σ | 0..0 | string | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept.coding.version Short descriptionVersion of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
string ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- v2: C*E.7
- rim: ./codeSystemVersion
- orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
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| code | Σ | 1..1 | code | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept.coding.code Short descriptionSymbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
Note that FHIR strings may not exceed 1MB in size
code ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Examples
SNOMED Code968211000000101 Mappings- rim: n/a
- v2: C*E.1
- rim: ./code
- orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 1..1 | string | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept.coding.display Short descriptionRepresentation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Note that FHIR strings may not exceed 1MB in size
string ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Examples
SNOMED DisplayLast months of life (finding) Mappings- rim: n/a
- v2: C*E.2 - but note this is not well followed
- rim: CV.displayName
- orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..0 | boolean | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept.coding.userSelected Short descriptionIf this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
boolean ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- v2: Sometimes implied by being first
- rim: CD.codingRationale
- orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| text | Σ | 1..1 | string | There are no (further) constraints on this element Element idClinicalImpression.prognosisCodeableConcept.text Short descriptionPrognosis DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Very often the text is the same as a displayName of one of the codings.
string ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings- rim: n/a
- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| prognosisReference | C | 0..0 | Reference(RiskAssessment) | There are no (further) constraints on this element Element idClinicalImpression.prognosisReference Short descriptionRiskAssessment expressing likely outcome DefinitionRiskAssessment expressing likely outcome.
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.
Reference(RiskAssessment) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
|
| action | C | 0..0 | Reference(Appointment | MedicationRequest | Procedure | ProcedureRequest | ReferralRequest) | There are no (further) constraints on this element Element idClinicalImpression.action Short descriptionAction 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(Appointment | MedicationRequest | Procedure | ProcedureRequest | ReferralRequest) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))
Mappings- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
|
| note | | 0..0 | Annotation | There are no (further) constraints on this element Element idClinicalImpression.note Short descriptionComments 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 ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() | (children().count() > id.count())
Mappings |
