- A clinical assessment performed when planning treatments and management strategies for a patient Base StructureDefinition for ClinicalImpression Resource
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Key: = Must support, = QICore-defined extension, = Is-Modifier
Field Card. Type and Description 
action 0..*List<ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticOrder | NutritionOrder | SupplyRequest | Appointment>Actions taken during assessment.assessor 0..1PractitionerThe clinician performing the assessment.date 0..1DateTimeThe point in time at which the assessment was concluded (not when it was recorded).description 0..1StringA summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/sstatus prompted it.finding 0..*List<Finding> (TBD)Specific findings or diagnoses that was considered likely or relevant to ongoing treatment.investigations 0..*List<Investigations> (TBD)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.patient 1..1PatientThe patient being assessed.plan 0..*List<CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription>Plan of action after assessment.previous 0..1ClinicalImpressionA 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.problem 0..*List<Condition | AllergyIntolerance>This a list of the general problems/conditions for a patient.prognosis 0..1StringEstimate of likely outcome.protocol 0..1UriReference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.resolved 0..*List<Concept>Diagnoses/conditions resolved since the last assessment.Binding: Condition/Problem/Diagnosis Codes (Example)
ruledOut 0..*List<RuledOut> (TBD)Diagnosis considered not possible.status 1..1codeIdentifies the workflow status of the assessment.Binding: ClinicalImpressionStatus (Required)
summary 0..1StringA text summary of the investigations and the diagnosis.trigger[x] 0..1Concept | ResourceThe request or event that necessitated this assessment. This may be a diagnosis, a Care Plan, a Request Referral, or some other resource.Binding: SNOMED CT Clinical Findings (Example)
Key: = Must support, = QICore-defined extension, = Is-Modifier
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