DSTU2 QA Preview
This page is part of the FHIR Specification (v1.0.0: DSTU 2 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4 R3 R2
StructureDefinition for clinicalimpression
{
"resourceType": "StructureDefinition",
"id": "ClinicalImpression",
"meta": {
"lastUpdated": "2015-09-01T14:38:48.206+10:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 0
}
],
"url": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression",
"name": "ClinicalImpression",
"status": "draft",
"publisher": "Health Level Seven International (Patient Care)",
"contact": [
{
"telecom": [
{
"system": "other",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "other",
"value": "http://www.hl7.org/Special/committees/patientcare/index.cfm"
}
]
}
],
"date": "2015-09-01T14:38:48+10:00",
"description": "Base StructureDefinition for ClinicalImpression Resource",
"mapping": [
{
"identity": "w5",
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping"
},
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM"
}
],
"kind": "resource",
"abstract": false,
"base": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"snapshot": {
"element": [
{
"path": "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.",
"min": 0,
"max": "*",
"type": [
{
"code": "DomainResource"
}
],
"mapping": [
{
"identity": "w5",
"map": "clinical.general"
}
]
},
{
"path": "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.",
"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. Bundles always have an id, though it is usually a generated UUID.",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"path": "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.",
"min": 0,
"max": "1",
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"path": "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.",
"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 as much as possible.",
"min": 0,
"max": "1",
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"path": "ClinicalImpression.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"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).",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"strength": "required",
"description": "A human language",
"valueSetUri": "http://tools.ietf.org/html/bcp47"
}
},
{
"path": "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.",
"comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"path": "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.",
"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.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "ClinicalImpression.patient",
"short": "The patient being assessed",
"definition": "The patient being assessed.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"path": "ClinicalImpression.assessor",
"short": "The clinician performing the assessment",
"definition": "The clinician performing the assessment.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"path": "ClinicalImpression.status",
"short": "in-progress | completed | entered-in-error",
"definition": "Identifies the workflow status of the assessment.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"strength": "required",
"description": "The workflow state of a clinical impression",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/clinical-impression-status"
}
},
"mapping": [
{
"identity": "w5",
"map": "status"
}
]
},
{
"path": "ClinicalImpression.date",
"short": "When the assessment occurred",
"definition": "The point in time at which the assessment was concluded (not when it was recorded).",
"comments": "This SHOULD be accurate to at least the minute, though some assessments only have a known date.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"path": "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 peformed, and what patient events/sstatus prompted it.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true
},
{
"path": "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.",
"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).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ClinicalImpression"
]
}
]
},
{
"path": "ClinicalImpression.problem",
"short": "General assessment of patient state",
"definition": "This a list of the general problems/conditions for a patient.",
"comments": "e.g. The patient is a pregnant, and cardiac congestive failure, Adenocarcinoma, and is allergic to penicillin.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Condition"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/AllergyIntolerance"
]
}
],
"isSummary": true
},
{
"path": "ClinicalImpression.trigger[x]",
"short": "Request or event that necessitated this assessment",
"definition": "The request or event that necessitated this assessment. This may be a diagnosis, a Care Plan, a Request Referral, or some other resource.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Resource"
]
}
],
"binding": {
"strength": "example",
"description": "Clinical Findings that may cause an clinical evaluation",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/clinical-findings"
}
}
},
{
"path": "ClinicalImpression.investigations",
"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.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"path": "ClinicalImpression.investigations.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "ClinicalImpression.investigations.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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "ClinicalImpression.investigations.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.",
"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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "ClinicalImpression.investigations.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.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "example",
"description": "A name/code for a set of investigations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/investigation-sets"
}
}
},
{
"path": "ClinicalImpression.investigations.item",
"short": "Record of a specific investigation",
"definition": "A record of a specific investigation that was undertaken.",
"comments": "Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Observation"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/DiagnosticReport"
]
}
]
},
{
"path": "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.",
"min": 0,
"max": "1",
"type": [
{
"code": "uri"
}
]
},
{
"path": "ClinicalImpression.summary",
"short": "Summary of the assessment",
"definition": "A text summary of the investigations and the diagnosis.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"path": "ClinicalImpression.finding",
"short": "Possible or likely findings and diagnoses",
"definition": "Specific findings or diagnoses that was considered likely or relevant to ongoing treatment.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"path": "ClinicalImpression.finding.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "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.",
"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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "ClinicalImpression.finding.item",
"short": "Specific text or code for finding",
"definition": "Specific text of code for finding or diagnosis.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "example",
"description": "Identification of the Condition or diagnosis.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-code"
}
}
},
{
"path": "ClinicalImpression.finding.cause",
"short": "Which investigations support finding",
"definition": "Which investigations support finding or diagnosis.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"path": "ClinicalImpression.resolved",
"short": "Diagnosies/conditions resolved since previous assessment",
"definition": "Diagnoses/conditions resolved since the last assessment.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "example",
"description": "Identification of the Condition or diagnosis.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-code"
}
}
},
{
"path": "ClinicalImpression.ruledOut",
"short": "Diagnosis considered not possible",
"definition": "Diagnosis considered not possible.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"path": "ClinicalImpression.ruledOut.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "ClinicalImpression.ruledOut.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.",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "ClinicalImpression.ruledOut.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.",
"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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "ClinicalImpression.ruledOut.item",
"short": "Specific text of code for diagnosis",
"definition": "Specific text of code for diagnosis.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "example",
"description": "Identification of the Condition or diagnosis.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-code"
}
}
},
{
"path": "ClinicalImpression.ruledOut.reason",
"short": "Grounds for elimination",
"definition": "Grounds for elimination.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"path": "ClinicalImpression.prognosis",
"short": "Estimate of likely outcome",
"definition": "Estimate of likely outcome.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"path": "ClinicalImpression.plan",
"short": "Plan of action after assessment",
"definition": "Plan of action after assessment.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/CarePlan"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Appointment"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/CommunicationRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/DeviceUseRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/DiagnosticOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/NutritionOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Order"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ProcedureRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ProcessRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ReferralRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SupplyRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/VisionPrescription"
]
}
]
},
{
"path": "ClinicalImpression.action",
"short": "Actions taken during assessment",
"definition": "Actions taken during assessment.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ReferralRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ProcedureRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Procedure"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/DiagnosticOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/NutritionOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SupplyRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Appointment"
]
}
]
}
]
},
"differential": {
"element": [
{
"path": "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.",
"min": 0,
"max": "*",
"type": [
{
"code": "DomainResource"
}
],
"mapping": [
{
"identity": "w5",
"map": "clinical.general"
}
]
},
{
"path": "ClinicalImpression.patient",
"short": "The patient being assessed",
"definition": "The patient being assessed.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"path": "ClinicalImpression.assessor",
"short": "The clinician performing the assessment",
"definition": "The clinician performing the assessment.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"path": "ClinicalImpression.status",
"short": "in-progress | completed | entered-in-error",
"definition": "Identifies the workflow status of the assessment.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"strength": "required",
"description": "The workflow state of a clinical impression",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/clinical-impression-status"
}
},
"mapping": [
{
"identity": "w5",
"map": "status"
}
]
},
{
"path": "ClinicalImpression.date",
"short": "When the assessment occurred",
"definition": "The point in time at which the assessment was concluded (not when it was recorded).",
"comments": "This SHOULD be accurate to at least the minute, though some assessments only have a known date.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"path": "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 peformed, and what patient events/sstatus prompted it.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true
},
{
"path": "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.",
"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).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ClinicalImpression"
]
}
]
},
{
"path": "ClinicalImpression.problem",
"short": "General assessment of patient state",
"definition": "This a list of the general problems/conditions for a patient.",
"comments": "e.g. The patient is a pregnant, and cardiac congestive failure, Adenocarcinoma, and is allergic to penicillin.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Condition"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/AllergyIntolerance"
]
}
],
"isSummary": true
},
{
"path": "ClinicalImpression.trigger[x]",
"short": "Request or event that necessitated this assessment",
"definition": "The request or event that necessitated this assessment. This may be a diagnosis, a Care Plan, a Request Referral, or some other resource.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Resource"
]
}
],
"binding": {
"strength": "example",
"description": "Clinical Findings that may cause an clinical evaluation",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/clinical-findings"
}
}
},
{
"path": "ClinicalImpression.investigations",
"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.",
"min": 0,
"max": "*"
},
{
"path": "ClinicalImpression.investigations.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.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "example",
"description": "A name/code for a set of investigations",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/investigation-sets"
}
}
},
{
"path": "ClinicalImpression.investigations.item",
"short": "Record of a specific investigation",
"definition": "A record of a specific investigation that was undertaken.",
"comments": "Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Observation"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/DiagnosticReport"
]
}
]
},
{
"path": "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.",
"min": 0,
"max": "1",
"type": [
{
"code": "uri"
}
]
},
{
"path": "ClinicalImpression.summary",
"short": "Summary of the assessment",
"definition": "A text summary of the investigations and the diagnosis.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"path": "ClinicalImpression.finding",
"short": "Possible or likely findings and diagnoses",
"definition": "Specific findings or diagnoses that was considered likely or relevant to ongoing treatment.",
"min": 0,
"max": "*"
},
{
"path": "ClinicalImpression.finding.item",
"short": "Specific text or code for finding",
"definition": "Specific text of code for finding or diagnosis.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "example",
"description": "Identification of the Condition or diagnosis.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-code"
}
}
},
{
"path": "ClinicalImpression.finding.cause",
"short": "Which investigations support finding",
"definition": "Which investigations support finding or diagnosis.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"path": "ClinicalImpression.resolved",
"short": "Diagnosies/conditions resolved since previous assessment",
"definition": "Diagnoses/conditions resolved since the last assessment.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "example",
"description": "Identification of the Condition or diagnosis.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-code"
}
}
},
{
"path": "ClinicalImpression.ruledOut",
"short": "Diagnosis considered not possible",
"definition": "Diagnosis considered not possible.",
"min": 0,
"max": "*"
},
{
"path": "ClinicalImpression.ruledOut.item",
"short": "Specific text of code for diagnosis",
"definition": "Specific text of code for diagnosis.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"strength": "example",
"description": "Identification of the Condition or diagnosis.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-code"
}
}
},
{
"path": "ClinicalImpression.ruledOut.reason",
"short": "Grounds for elimination",
"definition": "Grounds for elimination.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"path": "ClinicalImpression.prognosis",
"short": "Estimate of likely outcome",
"definition": "Estimate of likely outcome.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"path": "ClinicalImpression.plan",
"short": "Plan of action after assessment",
"definition": "Plan of action after assessment.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/CarePlan"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Appointment"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/CommunicationRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/DeviceUseRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/DiagnosticOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/NutritionOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Order"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ProcedureRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ProcessRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ReferralRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SupplyRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/VisionPrescription"
]
}
]
},
{
"path": "ClinicalImpression.action",
"short": "Actions taken during assessment",
"definition": "Actions taken during assessment.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ReferralRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/ProcedureRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Procedure"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/MedicationOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/DiagnosticOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/NutritionOrder"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/SupplyRequest"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Appointment"
]
}
]
}
]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
© HL7.org 2011+. FHIR DSTU2 (v1.0.0-6850) generated on Tue, Sep 1, 2015 14:41+1000.
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