2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

4.7 Resource ClinicalAssessment - Content

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.

4.7.1 Scope and 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 assessments are recorded. Some clinical assessments simply result in 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, the reasoning leading to a differential diagnosis, and the actions taken during or planned as a result of the clinical assessment, 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 partof an ongoing process of care, and the patient will be re-assessed repeatedly. For this reason, the clinical assessment can explicit reference both care plans (preceeding and resulting) and reference a previous assessment that this assessment follows on from.

Unlike many other resources, there is little prior art with regard to exchanging records of clinical assessments. For this reason, this resource should be regarded as particularly prone to ongoing revision. In terms of scope and usage, the Patient Care workgroup wishes to draw the attention of reviewers and implementers to the following issues:

  • When is an existing clinical assessment revised, rather than a new one created (that references the existing one)? How does that affect the status? what's the interplay between the status of the diagnosis and the status of the assesment? (e.g. for a 'provisional' assessment, which bit is provisional?)
  • This structure doesn't differentiate between a working and a final diagnosis. Given an answer to the previous question, should it?
  • Further clarify around the relationship between care plan and assessment is needed. Both answers to the previous questions and ongoing discussions around revisions to the care plan will influence the design of clinical assessment
  • Should prognosis be represented, and if so, how much structure should it have?
  • Should an assessment reference other assesments that are related? (how related?)
  • Investigations - the specification needs a good value set for the code for the group, and will be considering the name "investigations" further

4.7.2 Boundaries and Relationships

There is another related clinical concept often called an "assessment": assessment Tools such as Apgar (also known as "Assessment Scales"), and this is different to the scope of the "clinical assessment" resource. Assessment tools such as Apgar are represented as Observations, and Questionnaires may be used to help generate these. Clinical Assessments will often refer to these assessment tools as one of the investigations that was performed during the assessment process.

4.7.3 Background and Context

An important background to understanding this resource is the FHIR wiki page for clinical assessment. In particular, the storyboards there drove the design of the resource, and will be the basis for all examples created.

4.7.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalAssessment DomainResourceA clinical assessment performed when planning treatments and management strategies for a patient
... patient 1..1PatientThe patient being asssesed
... assessor 1..1PractitionerThe clinicial performing the assessment
... date 1..1dateTimeWhen the assessment occurred
... description 0..1stringWhy/how the assessment was performed
... previous 0..1ClinicalAssessmentReference to last assessment
... problem 0..*Condition | AllergyIntoleranceGeneral assessment of patient state
... careplan 0..1CarePlanA specific careplan that prompted this assessment
... referral 0..1ReferralRequestA specific referral that lead to this assessment
... investigations 0..*ElementOne or more sets of investigations (signs, symptions, etc)
.... code 1..1CodeableConceptA name/code for the set
investigationGroupType (Example)
.... item 0..*Observation | QuestionnaireAnswers | FamilyHistory | DiagnosticReportRecord of a specific investigation
... protocol 0..1uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... diagnosis 0..*ElementPossible or likely diagnosis
.... item 1..1CodeableConceptSpecific text or code for diagnosis
ConditionKind (Example)
.... cause 0..1stringWhich investigations support diagnosis
... resolved 0..*CodeableConceptDiagnosies/conditions resolved since previous assessment
ConditionKind (Example)
... ruledOut 0..*ElementDiagnosis considered not possible
.... item 1..1CodeableConceptSpecific text of code for diagnosis
ConditionKind (Example)
.... reason 0..1stringGrounds for elimination
... prognosis 0..1stringEstimate of likely outcome
... plan 0..1CarePlanPlan of action after assessment
... action 0..*ReferralRequest | ProcedureRequest | Procedure | MedicationPrescription | DiagnosticOrder | NutritionOrder | Supply | AppointmentActions taken during assessment

UML Diagram

ClinicalAssessment (DomainResource)The patient being asssesedpatient : Reference(Patient) 1..1The clinicial performing the assessmentassessor : Reference(Practitioner) 1..1The point in time at which the assessment was concluded (not when it was recorded)date : dateTime 1..1A summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/sstatus prompted itdescription : string 0..1A 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 changesprevious : Reference(ClinicalAssessment) 0..1This a list of the general problems/conditions for a patientproblem : Reference(Condition|AllergyIntolerance) 0..*A reference to a specific care plan that prompted this assessment. The care plan provides further context for the assessmentcareplan : Reference(CarePlan) 0..1A reference to a specific care plan that prompted this assessment. The referral request may provide further context for the assessmentreferral : Reference(ReferralRequest) 0..1Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosisprotocol : uri 0..1A text summary of the investigations and the diagnosissummary : string 0..1Diagnoses/conditions resolved since the last assessmentresolved : CodeableConcept 0..* « (Identification of the Condition or diagnosis.ConditionKind) »Estimate of likely outcomeprognosis : string 0..1Plan of action after assessmentplan : Reference(CarePlan) 0..1Actions taken during assessmentaction : Reference(ReferralRequest| ProcedureRequest|Procedure| MedicationPrescription|DiagnosticOrder| NutritionOrder|Supply|Appointment) 0..*InvestigationsA 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 usedcode : CodeableConcept 1..1 « (A name/code for a set of investigationsinvestigationGroupType) »A record of a specific investigation that was undertakenitem : Reference(Observation| QuestionnaireAnswers|FamilyHistory| DiagnosticReport) 0..*DiagnosisSpecific text of code for diagnosisitem : CodeableConcept 1..1 « (Identification of the Condition or diagnosis.ConditionKind) »Which investigations support diagnosiscause : string 0..1RuledOutSpecific text of code for diagnosisitem : CodeableConcept 1..1 « (Identification of the Condition or diagnosis.ConditionKind) »Grounds for eliminationreason : string 0..1One 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 outcomesinvestigations0..*An specific diagnosis that was considered likely or relevant to ongoing treatmentdiagnosis0..*Diagnosis considered not possibleruledOut0..*

XML Template

<ClinicalAssessment xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <patient><!-- 1..1 Reference(Patient) The patient being asssesed --></patient>
 <assessor><!-- 1..1 Reference(Practitioner) The clinicial performing the assessment --></assessor>
 <date value="[dateTime]"/><!-- 1..1 When the assessment occurred -->
 <description value="[string]"/><!-- 0..1 Why/how the assessment was performed -->
 <previous><!-- 0..1 Reference(ClinicalAssessment) Reference to last assessment --></previous>
 <problem><!-- 0..* Reference(Condition|AllergyIntolerance) 
     General assessment of patient state --></problem>
 <careplan><!-- 0..1 Reference(CarePlan) A specific careplan that prompted this assessment --></careplan>
 <referral><!-- 0..1 Reference(ReferralRequest) 
     A specific referral that lead to this assessment --></referral>
 <investigations>  <!-- 0..* One or more sets of investigations (signs, symptions, etc) -->
  <code><!-- 1..1 CodeableConcept A name/code for the set --></code>
  <item><!-- 0..* Reference(Observation|QuestionnaireAnswers|FamilyHistory|
    DiagnosticReport) Record of a specific investigation --></item>
 </investigations>
 <protocol value="[uri]"/><!-- 0..1 Clinical Protocol followed -->
 <summary value="[string]"/><!-- 0..1 Summary of the assessment -->
 <diagnosis>  <!-- 0..* Possible or likely diagnosis -->
  <item><!-- 1..1 CodeableConcept Specific text or code for diagnosis --></item>
  <cause value="[string]"/><!-- 0..1 Which investigations support diagnosis -->
 </diagnosis>
 <resolved><!-- 0..* CodeableConcept Diagnosies/conditions resolved since previous assessment --></resolved>
 <ruledOut>  <!-- 0..* Diagnosis considered not possible -->
  <item><!-- 1..1 CodeableConcept Specific text of code for diagnosis --></item>
  <reason value="[string]"/><!-- 0..1 Grounds for elimination -->
 </ruledOut>
 <prognosis value="[string]"/><!-- 0..1 Estimate of likely outcome -->
 <plan><!-- 0..1 Reference(CarePlan) Plan of action after assessment --></plan>
 <action><!-- 0..* Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationPrescription|DiagnosticOrder|NutritionOrder|Supply|Appointment) 
     Actions taken during assessment --></action>
</ClinicalAssessment>

JSON Template

{doco
  "resourceType" : "ClinicalAssessment",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "patient" : { Reference(Patient) }, // R! The patient being asssesed
  "assessor" : { Reference(Practitioner) }, // R! The clinicial performing the assessment
  "date" : "<dateTime>", // R! When the assessment occurred
  "description" : "<string>", // Why/how the assessment was performed
  "previous" : { Reference(ClinicalAssessment) }, // Reference to last assessment
  "problem" : [{ Reference(Condition|AllergyIntolerance) }], // 
     General assessment of patient state
  "careplan" : { Reference(CarePlan) }, // A specific careplan that prompted this assessment
  "referral" : { Reference(ReferralRequest) }, // 
     A specific referral that lead to this assessment
  "investigations" : [{ // One or more sets of investigations (signs, symptions, etc)
    "code" : { CodeableConcept }, // R! A name/code for the set
    "item" : [{ Reference(Observation|QuestionnaireAnswers|FamilyHistory|
    DiagnosticReport) }] // Record of a specific investigation
  }],
  "protocol" : "<uri>", // Clinical Protocol followed
  "summary" : "<string>", // Summary of the assessment
  "diagnosis" : [{ // Possible or likely diagnosis
    "item" : { CodeableConcept }, // R! Specific text or code for diagnosis
    "cause" : "<string>" // Which investigations support diagnosis
  }],
  "resolved" : [{ CodeableConcept }], // Diagnosies/conditions resolved since previous assessment
  "ruledOut" : [{ // Diagnosis considered not possible
    "item" : { CodeableConcept }, // R! Specific text of code for diagnosis
    "reason" : "<string>" // Grounds for elimination
  }],
  "prognosis" : "<string>", // Estimate of likely outcome
  "plan" : { Reference(CarePlan) }, // Plan of action after assessment
  "action" : [{ Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationPrescription|DiagnosticOrder|NutritionOrder|Supply|Appointment) }] // 
     Actions taken during assessment
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalAssessment DomainResourceA clinical assessment performed when planning treatments and management strategies for a patient
... patient 1..1PatientThe patient being asssesed
... assessor 1..1PractitionerThe clinicial performing the assessment
... date 1..1dateTimeWhen the assessment occurred
... description 0..1stringWhy/how the assessment was performed
... previous 0..1ClinicalAssessmentReference to last assessment
... problem 0..*Condition | AllergyIntoleranceGeneral assessment of patient state
... careplan 0..1CarePlanA specific careplan that prompted this assessment
... referral 0..1ReferralRequestA specific referral that lead to this assessment
... investigations 0..*ElementOne or more sets of investigations (signs, symptions, etc)
.... code 1..1CodeableConceptA name/code for the set
investigationGroupType (Example)
.... item 0..*Observation | QuestionnaireAnswers | FamilyHistory | DiagnosticReportRecord of a specific investigation
... protocol 0..1uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... diagnosis 0..*ElementPossible or likely diagnosis
.... item 1..1CodeableConceptSpecific text or code for diagnosis
ConditionKind (Example)
.... cause 0..1stringWhich investigations support diagnosis
... resolved 0..*CodeableConceptDiagnosies/conditions resolved since previous assessment
ConditionKind (Example)
... ruledOut 0..*ElementDiagnosis considered not possible
.... item 1..1CodeableConceptSpecific text of code for diagnosis
ConditionKind (Example)
.... reason 0..1stringGrounds for elimination
... prognosis 0..1stringEstimate of likely outcome
... plan 0..1CarePlanPlan of action after assessment
... action 0..*ReferralRequest | ProcedureRequest | Procedure | MedicationPrescription | DiagnosticOrder | NutritionOrder | Supply | AppointmentActions taken during assessment

UML Diagram

ClinicalAssessment (DomainResource)The patient being asssesedpatient : Reference(Patient) 1..1The clinicial performing the assessmentassessor : Reference(Practitioner) 1..1The point in time at which the assessment was concluded (not when it was recorded)date : dateTime 1..1A summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/sstatus prompted itdescription : string 0..1A 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 changesprevious : Reference(ClinicalAssessment) 0..1This a list of the general problems/conditions for a patientproblem : Reference(Condition|AllergyIntolerance) 0..*A reference to a specific care plan that prompted this assessment. The care plan provides further context for the assessmentcareplan : Reference(CarePlan) 0..1A reference to a specific care plan that prompted this assessment. The referral request may provide further context for the assessmentreferral : Reference(ReferralRequest) 0..1Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosisprotocol : uri 0..1A text summary of the investigations and the diagnosissummary : string 0..1Diagnoses/conditions resolved since the last assessmentresolved : CodeableConcept 0..* « (Identification of the Condition or diagnosis.ConditionKind) »Estimate of likely outcomeprognosis : string 0..1Plan of action after assessmentplan : Reference(CarePlan) 0..1Actions taken during assessmentaction : Reference(ReferralRequest| ProcedureRequest|Procedure| MedicationPrescription|DiagnosticOrder| NutritionOrder|Supply|Appointment) 0..*InvestigationsA 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 usedcode : CodeableConcept 1..1 « (A name/code for a set of investigationsinvestigationGroupType) »A record of a specific investigation that was undertakenitem : Reference(Observation| QuestionnaireAnswers|FamilyHistory| DiagnosticReport) 0..*DiagnosisSpecific text of code for diagnosisitem : CodeableConcept 1..1 « (Identification of the Condition or diagnosis.ConditionKind) »Which investigations support diagnosiscause : string 0..1RuledOutSpecific text of code for diagnosisitem : CodeableConcept 1..1 « (Identification of the Condition or diagnosis.ConditionKind) »Grounds for eliminationreason : string 0..1One 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 outcomesinvestigations0..*An specific diagnosis that was considered likely or relevant to ongoing treatmentdiagnosis0..*Diagnosis considered not possibleruledOut0..*

XML Template

<ClinicalAssessment xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <patient><!-- 1..1 Reference(Patient) The patient being asssesed --></patient>
 <assessor><!-- 1..1 Reference(Practitioner) The clinicial performing the assessment --></assessor>
 <date value="[dateTime]"/><!-- 1..1 When the assessment occurred -->
 <description value="[string]"/><!-- 0..1 Why/how the assessment was performed -->
 <previous><!-- 0..1 Reference(ClinicalAssessment) Reference to last assessment --></previous>
 <problem><!-- 0..* Reference(Condition|AllergyIntolerance) 
     General assessment of patient state --></problem>
 <careplan><!-- 0..1 Reference(CarePlan) A specific careplan that prompted this assessment --></careplan>
 <referral><!-- 0..1 Reference(ReferralRequest) 
     A specific referral that lead to this assessment --></referral>
 <investigations>  <!-- 0..* One or more sets of investigations (signs, symptions, etc) -->
  <code><!-- 1..1 CodeableConcept A name/code for the set --></code>
  <item><!-- 0..* Reference(Observation|QuestionnaireAnswers|FamilyHistory|
    DiagnosticReport) Record of a specific investigation --></item>
 </investigations>
 <protocol value="[uri]"/><!-- 0..1 Clinical Protocol followed -->
 <summary value="[string]"/><!-- 0..1 Summary of the assessment -->
 <diagnosis>  <!-- 0..* Possible or likely diagnosis -->
  <item><!-- 1..1 CodeableConcept Specific text or code for diagnosis --></item>
  <cause value="[string]"/><!-- 0..1 Which investigations support diagnosis -->
 </diagnosis>
 <resolved><!-- 0..* CodeableConcept Diagnosies/conditions resolved since previous assessment --></resolved>
 <ruledOut>  <!-- 0..* Diagnosis considered not possible -->
  <item><!-- 1..1 CodeableConcept Specific text of code for diagnosis --></item>
  <reason value="[string]"/><!-- 0..1 Grounds for elimination -->
 </ruledOut>
 <prognosis value="[string]"/><!-- 0..1 Estimate of likely outcome -->
 <plan><!-- 0..1 Reference(CarePlan) Plan of action after assessment --></plan>
 <action><!-- 0..* Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationPrescription|DiagnosticOrder|NutritionOrder|Supply|Appointment) 
     Actions taken during assessment --></action>
</ClinicalAssessment>

JSON Template

{doco
  "resourceType" : "ClinicalAssessment",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "patient" : { Reference(Patient) }, // R! The patient being asssesed
  "assessor" : { Reference(Practitioner) }, // R! The clinicial performing the assessment
  "date" : "<dateTime>", // R! When the assessment occurred
  "description" : "<string>", // Why/how the assessment was performed
  "previous" : { Reference(ClinicalAssessment) }, // Reference to last assessment
  "problem" : [{ Reference(Condition|AllergyIntolerance) }], // 
     General assessment of patient state
  "careplan" : { Reference(CarePlan) }, // A specific careplan that prompted this assessment
  "referral" : { Reference(ReferralRequest) }, // 
     A specific referral that lead to this assessment
  "investigations" : [{ // One or more sets of investigations (signs, symptions, etc)
    "code" : { CodeableConcept }, // R! A name/code for the set
    "item" : [{ Reference(Observation|QuestionnaireAnswers|FamilyHistory|
    DiagnosticReport) }] // Record of a specific investigation
  }],
  "protocol" : "<uri>", // Clinical Protocol followed
  "summary" : "<string>", // Summary of the assessment
  "diagnosis" : [{ // Possible or likely diagnosis
    "item" : { CodeableConcept }, // R! Specific text or code for diagnosis
    "cause" : "<string>" // Which investigations support diagnosis
  }],
  "resolved" : [{ CodeableConcept }], // Diagnosies/conditions resolved since previous assessment
  "ruledOut" : [{ // Diagnosis considered not possible
    "item" : { CodeableConcept }, // R! Specific text of code for diagnosis
    "reason" : "<string>" // Grounds for elimination
  }],
  "prognosis" : "<string>", // Estimate of likely outcome
  "plan" : { Reference(CarePlan) }, // Plan of action after assessment
  "action" : [{ Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationPrescription|DiagnosticOrder|NutritionOrder|Supply|Appointment) }] // 
     Actions taken during assessment
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

4.7.4.1 Terminology Bindings

PathDefinitionTypeReference
ClinicalAssessment.investigations.code A name/code for a set of investigationsExamplehttp://hl7.org/fhir/vs/investigation-sets
ClinicalAssessment.diagnosis.item
ClinicalAssessment.resolved
ClinicalAssessment.ruledOut.item 		Identification of the Condition or diagnosis.Examplehttp://hl7.org/fhir/vs/condition-code

4.7.5 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
actionreferenceActions taken during assessmentClinicalAssessment.action
(Supply, ReferralRequest, Appointment, ProcedureRequest, MedicationPrescription, Procedure, NutritionOrder, DiagnosticOrder)
assessorreferenceThe clinicial performing the assessmentClinicalAssessment.assessor
(Practitioner)
careplanreferenceA specific careplan that prompted this assessmentClinicalAssessment.careplan
(CarePlan)
datedateWhen the assessment occurredClinicalAssessment.date
diagnosistokenSpecific text or code for diagnosisClinicalAssessment.diagnosis.item
investigationreferenceRecord of a specific investigationClinicalAssessment.investigations.item
(FamilyHistory, QuestionnaireAnswers, Observation, DiagnosticReport)
patientreferenceThe patient being asssesedClinicalAssessment.patient
(Patient)
planreferencePlan of action after assessmentClinicalAssessment.plan
(CarePlan)
previousreferenceReference to last assessmentClinicalAssessment.previous
(ClinicalAssessment)
problemreferenceGeneral assessment of patient stateClinicalAssessment.problem
(Condition, AllergyIntolerance)
referralreferenceA specific referral that lead to this assessmentClinicalAssessment.referral
(ReferralRequest)
resolvedtokenDiagnosies/conditions resolved since previous assessmentClinicalAssessment.resolved
ruledouttokenSpecific text of code for diagnosisClinicalAssessment.ruledOut.item