STU 3 Ballot

This page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). 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

9.6 Resource ClinicalImpression - Content

Patient Care Work GroupMaturity Level: 0Compartments: Encounter, Patient, Practitioner

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.

9.6.1 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 impressions are recorded. Some clinical assessments simply result in an impression recorded as 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 part of an ongoing process of care, and the patient will be re-assessed repeatedly. For this reason, the clinical impression can explicit reference both care plans (preceeding and resulting) and reference a previous impression that this impression follows on from.

An impression is a clinical summation of information and/or an opinion formed, which is the outcome of the clinical assessment process. The ClinicalImpression may lead to a statement of a Condition about a patient.

In FHIR, an assessment is typically an instrument or tool used to collect information about a patient.

DSTU Note: 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 impression 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 impression? (e.g. for a 'provisional' impression, 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 impression is needed. Both answers to the previous questions and ongoing discussions around revisions to the care plan will influence the design of clinical impression
  • Should prognosis be represented, and if so, how much structure should it have?
  • Should an impression reference other impressions 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

Feedback is welcome here .

9.6.2 Boundaries and Relationships

There is another related clinical concept often called an "assessment": assessment Tools such as Apgar (also known as "Assessment Scales"). This is not what the ClinicalImpression resource is about; assessment tools such as Apgar are represented as Observations, and Questionnaires may be used to help generate these. Clinical Impressions may refer to these assessment tools as one of the investigations that was performed during the assessment process.

9.6.3 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.

PLANNED CHANGE:

Communication is one of the Event resources in the FHIR Workflow specification. As such, it is expected to be adjusted to align with the Event workflow pattern which will involve adding a number of additional data elements and potentially renaming a few elements. Any concerns about performing such alignment are welcome as ballot comments and/or tracker items.

This resource is referenced by condition

9.6.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression DomainResourceA clinical assessment performed when planning treatments and management strategies for a patient
... identifier Σ0..*IdentifierBusiness identifier
... status ?!Σ1..1codedraft | completed | entered-in-error
ClinicalImpressionStatus (Required)
... code Σ0..1CodeableConceptKind of impression performed
... description Σ0..1stringWhy/how the assessment was performed
... subject Σ1..1Reference(Patient | Group)Patient or group assessed
... assessor Σ0..1Reference(Practitioner)The clinician performing the assessment
... date Σ0..1dateTimeWhen the assessment was documented
... effective[x] Σ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... context Σ0..1Reference(Encounter | EpisodeOfCare)Encounter or Episode created from
... previous 0..1Reference(ClinicalImpression)Reference to last assessment
... problem Σ0..*Reference(Condition | AllergyIntolerance)Relevant impressions of patient state
... investigations 0..*BackboneElementOne or more sets of investigations (signs, symptions, etc.)
.... code 1..1CodeableConceptA name/code for the set
Investigation Type (Example)
.... item 0..*Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy)Record of a specific investigation
... protocol 0..*uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... finding 0..*BackboneElementPossible or likely findings and diagnoses
.... item[x] 1..1What was found
Condition/Problem/Diagnosis Codes (Example)
..... itemCodeableConceptCodeableConcept
..... itemReferenceReference(Condition | Observation)
.... cause 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate of likely outcome
Clinical Impression Prognosis (Example)
... prognosisReference 0..*Reference(RiskAssessment)RiskAssessment expressing likely outcome
... plan 0..*Reference(CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticRequest | MedicationOrder | NutritionRequest | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription)Plan of action after assessment
... action 0..*Reference(ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticRequest | NutritionRequest | SupplyRequest | Appointment)Actions taken during assessment
... note 0..*AnnotationComments made about the ClinicalImpression

doco Documentation for this format

UML Diagram (Legend)

ClinicalImpression (DomainResource)A unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored onidentifier : Identifier [0..*]Identifies the workflow status of the assessment (this element modifies the meaning of other elements)status : code [1..1] « The workflow state of a clinical impression. (Strength=Required)ClinicalImpressionStatus! »Categorizes the type of clinical impression performedcode : CodeableConcept [0..1]A summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/status prompted itdescription : string [0..1]The patient or group of individuals assessed as part of this recordsubject : Reference [1..1] « Patient|Group »The clinician performing the assessmentassessor : Reference [0..1] « Practitioner »Indicates when the documentation of the assessment was completedate : dateTime [0..1]The point in time or period over which the subject was assessedeffective[x] : Type [0..1] « dateTime|Period »The encounter or episode of care this impression was created as part ofcontext : Reference [0..1] « Encounter|EpisodeOfCare »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 changesprevious : Reference [0..1] « ClinicalImpression »This a list of the relevant problems/conditions for a patientproblem : Reference [0..*] « Condition|AllergyIntolerance »Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosisprotocol : uri [0..*]A text summary of the investigations and the diagnosissummary : string [0..1]Estimate of likely outcomeprognosisCodeableConcept : CodeableConcept [0..*] « Prognosis or outlook findings (Strength=Example)Clinical Impression Prognosis?? »RiskAssessment expressing likely outcomeprognosisReference : Reference [0..*] « RiskAssessment »Plan of action after assessmentplan : Reference [0..*] « CarePlan|Appointment|CommunicationRequest| DeviceUseRequest|DiagnosticRequest|MedicationOrder| NutritionRequest|ProcedureRequest|ProcessRequest| ReferralRequest|SupplyRequest|VisionPrescription »Actions taken during assessmentaction : Reference [0..*] « ReferralRequest|ProcedureRequest| Procedure|MedicationOrder|DiagnosticRequest|NutritionRequest| SupplyRequest|Appointment »Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appearnote : Annotation [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 investigations. (Strength=Example)Investigation Type?? »A record of a specific investigation that was undertakenitem : Reference [0..*] « Observation|QuestionnaireResponse| FamilyMemberHistory|DiagnosticReport|RiskAssessment| ImagingStudy »FindingSpecific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditionsitem[x] : Type [1..1] « CodeableConcept|Reference(Condition| Observation); Identification of the Condition or diagnosis. (Strength=Example)Condition/Problem/Diagnosis ?? »Which investigations support finding or diagnosiscause : string [0..1]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 outcomesinvestigations[0..*]Specific findings or diagnoses that was considered likely or relevant to ongoing treatmentfinding[0..*]

XML Template

<ClinicalImpression xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business identifier --></identifier>
 <status value="[code]"/><!-- 1..1 draft | completed | entered-in-error -->
 <code><!-- 0..1 CodeableConcept Kind of impression performed --></code>
 <description value="[string]"/><!-- 0..1 Why/how the assessment was performed -->
 <subject><!-- 1..1 Reference(Patient|Group) Patient or group assessed --></subject>
 <assessor><!-- 0..1 Reference(Practitioner) The clinician performing the assessment --></assessor>
 <date value="[dateTime]"/><!-- 0..1 When the assessment was documented -->
 <effective[x]><!-- 0..1 dateTime|Period Time of assessment --></effective[x]>
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Encounter or Episode created from --></context>
 <previous><!-- 0..1 Reference(ClinicalImpression) Reference to last assessment --></previous>
 <problem><!-- 0..* Reference(Condition|AllergyIntolerance) Relevant impressions of patient state --></problem>
 <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|QuestionnaireResponse|FamilyMemberHistory|
    DiagnosticReport|RiskAssessment|ImagingStudy) Record of a specific investigation --></item>
 </investigations>
 <protocol value="[uri]"/><!-- 0..* Clinical Protocol followed -->
 <summary value="[string]"/><!-- 0..1 Summary of the assessment -->
 <finding>  <!-- 0..* Possible or likely findings and diagnoses -->
  <item[x]><!-- 1..1 CodeableConcept|Reference(Condition|Observation) What was found --></item[x]>
  <cause value="[string]"/><!-- 0..1 Which investigations support finding -->
 </finding>
 <prognosisCodeableConcept><!-- 0..* CodeableConcept Estimate of likely outcome --></prognosisCodeableConcept>
 <prognosisReference><!-- 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome --></prognosisReference>
 <plan><!-- 0..* Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticRequest|MedicationOrder|NutritionRequest|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) Plan of action after assessment --></plan>
 <action><!-- 0..* Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticRequest|NutritionRequest|SupplyRequest|Appointment) Actions taken during assessment --></action>
 <note><!-- 0..* Annotation Comments made about the ClinicalImpression --></note>
</ClinicalImpression>

JSON Template

{doco
  "resourceType" : "ClinicalImpression",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business identifier
  "status" : "<code>", // R!  draft | completed | entered-in-error
  "code" : { CodeableConcept }, // Kind of impression performed
  "description" : "<string>", // Why/how the assessment was performed
  "subject" : { Reference(Patient|Group) }, // R!  Patient or group assessed
  "assessor" : { Reference(Practitioner) }, // The clinician performing the assessment
  "date" : "<dateTime>", // When the assessment was documented
  // effective[x]: Time of assessment. One of these 2:
  "effectiveDateTime" : "<dateTime>",
  "effectivePeriod" : { Period },
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Encounter or Episode created from
  "previous" : { Reference(ClinicalImpression) }, // Reference to last assessment
  "problem" : [{ Reference(Condition|AllergyIntolerance) }], // Relevant impressions of patient state
  "investigations" : [{ // One or more sets of investigations (signs, symptions, etc.)
    "code" : { CodeableConcept }, // R!  A name/code for the set
    "item" : [{ Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|
    DiagnosticReport|RiskAssessment|ImagingStudy) }] // Record of a specific investigation
  }],
  "protocol" : ["<uri>"], // Clinical Protocol followed
  "summary" : "<string>", // Summary of the assessment
  "finding" : [{ // Possible or likely findings and diagnoses
    // item[x]: What was found. One of these 2:
    "itemCodeableConcept" : { CodeableConcept },
    "itemReference" : { Reference(Condition|Observation) },
    "cause" : "<string>" // Which investigations support finding
  }],
  "prognosisCodeableConcept" : [{ CodeableConcept }], // Estimate of likely outcome
  "prognosisReference" : [{ Reference(RiskAssessment) }], // RiskAssessment expressing likely outcome
  "plan" : [{ Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticRequest|MedicationOrder|NutritionRequest|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) }], // Plan of action after assessment
  "action" : [{ Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticRequest|NutritionRequest|SupplyRequest|Appointment) }], // Actions taken during assessment
  "note" : [{ Annotation }] // Comments made about the ClinicalImpression
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClinicalImpression;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClinicalImpression.identifier [ Identifier ], ... ; # 0..* Business identifier
  fhir:ClinicalImpression.status [ code ]; # 1..1 draft | completed | entered-in-error
  fhir:ClinicalImpression.code [ CodeableConcept ]; # 0..1 Kind of impression performed
  fhir:ClinicalImpression.description [ string ]; # 0..1 Why/how the assessment was performed
  fhir:ClinicalImpression.subject [ Reference(Patient|Group) ]; # 1..1 Patient or group assessed
  fhir:ClinicalImpression.assessor [ Reference(Practitioner) ]; # 0..1 The clinician performing the assessment
  fhir:ClinicalImpression.date [ dateTime ]; # 0..1 When the assessment was documented
  # ClinicalImpression.effective[x] : 0..1 Time of assessment. One of these 2
    fhir:ClinicalImpression.effectiveDateTime [ dateTime ]
    fhir:ClinicalImpression.effectivePeriod [ Period ]
  fhir:ClinicalImpression.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Encounter or Episode created from
  fhir:ClinicalImpression.previous [ Reference(ClinicalImpression) ]; # 0..1 Reference to last assessment
  fhir:ClinicalImpression.problem [ Reference(Condition|AllergyIntolerance) ], ... ; # 0..* Relevant impressions of patient state
  fhir:ClinicalImpression.investigations [ # 0..* One or more sets of investigations (signs, symptions, etc.)
    fhir:ClinicalImpression.investigations.code [ CodeableConcept ]; # 1..1 A name/code for the set
    fhir:ClinicalImpression.investigations.item [ Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|DiagnosticReport|
  RiskAssessment|ImagingStudy) ], ... ; # 0..* Record of a specific investigation
  ], ...;
  fhir:ClinicalImpression.protocol [ uri ], ... ; # 0..* Clinical Protocol followed
  fhir:ClinicalImpression.summary [ string ]; # 0..1 Summary of the assessment
  fhir:ClinicalImpression.finding [ # 0..* Possible or likely findings and diagnoses
    # ClinicalImpression.finding.item[x] : 1..1 What was found. One of these 2
      fhir:ClinicalImpression.finding.itemCodeableConcept [ CodeableConcept ]
      fhir:ClinicalImpression.finding.itemReference [ Reference(Condition|Observation) ]
    fhir:ClinicalImpression.finding.cause [ string ]; # 0..1 Which investigations support finding
  ], ...;
  fhir:ClinicalImpression.prognosisCodeableConcept [ CodeableConcept ], ... ; # 0..* Estimate of likely outcome
  fhir:ClinicalImpression.prognosisReference [ Reference(RiskAssessment) ], ... ; # 0..* RiskAssessment expressing likely outcome
  fhir:ClinicalImpression.plan [ Reference(CarePlan|Appointment|CommunicationRequest|DeviceUseRequest|DiagnosticRequest|
  MedicationOrder|NutritionRequest|ProcedureRequest|ProcessRequest|
  ReferralRequest|SupplyRequest|VisionPrescription) ], ... ; # 0..* Plan of action after assessment
  fhir:ClinicalImpression.action [ Reference(ReferralRequest|ProcedureRequest|Procedure|MedicationOrder|DiagnosticRequest|
  NutritionRequest|SupplyRequest|Appointment) ], ... ; # 0..* Actions taken during assessment
  fhir:ClinicalImpression.note [ Annotation ], ... ; # 0..* Comments made about the ClinicalImpression
]

Changes since DSTU2

ClinicalImpression
ClinicalImpression.identifier added
ClinicalImpression.code added
ClinicalImpression.subject Renamed from patient to subject
Add Reference(Group)
ClinicalImpression.effective[x] added
ClinicalImpression.context added
ClinicalImpression.investigations.item Add Reference(RiskAssessment), Add Reference(ImagingStudy)
ClinicalImpression.protocol Max Cardinality changed from 1 to *
ClinicalImpression.finding.item[x] Renamed from item to item[x]
Add Reference(Condition), Add Reference(Observation)
ClinicalImpression.prognosisCodeableConcept added
ClinicalImpression.prognosisReference added
ClinicalImpression.plan Remove Reference(DiagnosticOrder), Remove Reference(NutritionOrder), Remove Reference(Order), Add Reference(DiagnosticRequest), Add Reference(NutritionRequest)
ClinicalImpression.action Remove Reference(DiagnosticOrder), Remove Reference(NutritionOrder), Add Reference(DiagnosticRequest), Add Reference(NutritionRequest)
ClinicalImpression.note added
ClinicalImpression.trigger[x] deleted
ClinicalImpression.resolved deleted
ClinicalImpression.ruledOut deleted
ClinicalImpression.prognosis deleted

See the Full Difference for further information

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression DomainResourceA clinical assessment performed when planning treatments and management strategies for a patient
... identifier Σ0..*IdentifierBusiness identifier
... status ?!Σ1..1codedraft | completed | entered-in-error
ClinicalImpressionStatus (Required)
... code Σ0..1CodeableConceptKind of impression performed
... description Σ0..1stringWhy/how the assessment was performed
... subject Σ1..1Reference(Patient | Group)Patient or group assessed
... assessor Σ0..1Reference(Practitioner)The clinician performing the assessment
... date Σ0..1dateTimeWhen the assessment was documented
... effective[x] Σ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... context Σ0..1Reference(Encounter | EpisodeOfCare)Encounter or Episode created from
... previous 0..1Reference(ClinicalImpression)Reference to last assessment
... problem Σ0..*Reference(Condition | AllergyIntolerance)Relevant impressions of patient state
... investigations 0..*BackboneElementOne or more sets of investigations (signs, symptions, etc.)
.... code 1..1CodeableConceptA name/code for the set
Investigation Type (Example)
.... item 0..*Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy)Record of a specific investigation
... protocol 0..*uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... finding 0..*BackboneElementPossible or likely findings and diagnoses
.... item[x] 1..1What was found
Condition/Problem/Diagnosis Codes (Example)
..... itemCodeableConceptCodeableConcept
..... itemReferenceReference(Condition | Observation)
.... cause 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate of likely outcome
Clinical Impression Prognosis (Example)
... prognosisReference 0..*Reference(RiskAssessment)RiskAssessment expressing likely outcome
... plan 0..*Reference(CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticRequest | MedicationOrder | NutritionRequest | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription)Plan of action after assessment
... action 0..*Reference(ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticRequest | NutritionRequest | SupplyRequest | Appointment)Actions taken during assessment
... note 0..*AnnotationComments made about the ClinicalImpression

doco Documentation for this format

UML Diagram (Legend)

ClinicalImpression (DomainResource)A unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored onidentifier : Identifier [0..*]Identifies the workflow status of the assessment (this element modifies the meaning of other elements)status : code [1..1] « The workflow state of a clinical impression. (Strength=Required)ClinicalImpressionStatus! »Categorizes the type of clinical impression performedcode : CodeableConcept [0..1]A summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/status prompted itdescription : string [0..1]The patient or group of individuals assessed as part of this recordsubject : Reference [1..1] « Patient|Group »The clinician performing the assessmentassessor : Reference [0..1] « Practitioner »Indicates when the documentation of the assessment was completedate : dateTime [0..1]The point in time or period over which the subject was assessedeffective[x] : Type [0..1] « dateTime|Period »The encounter or episode of care this impression was created as part ofcontext : Reference [0..1] « Encounter|EpisodeOfCare »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 changesprevious : Reference [0..1] « ClinicalImpression »This a list of the relevant problems/conditions for a patientproblem : Reference [0..*] « Condition|AllergyIntolerance »Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosisprotocol : uri [0..*]A text summary of the investigations and the diagnosissummary : string [0..1]Estimate of likely outcomeprognosisCodeableConcept : CodeableConcept [0..*] « Prognosis or outlook findings (Strength=Example)Clinical Impression Prognosis?? »RiskAssessment expressing likely outcomeprognosisReference : Reference [0..*] « RiskAssessment »Plan of action after assessmentplan : Reference [0..*] « CarePlan|Appointment|CommunicationRequest| DeviceUseRequest|DiagnosticRequest|MedicationOrder| NutritionRequest|ProcedureRequest|ProcessRequest| ReferralRequest|SupplyRequest|VisionPrescription »Actions taken during assessmentaction : Reference [0..*] « ReferralRequest|ProcedureRequest| Procedure|MedicationOrder|DiagnosticRequest|NutritionRequest| SupplyRequest|Appointment »Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appearnote : Annotation [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 investigations. (Strength=Example)Investigation Type?? »A record of a specific investigation that was undertakenitem : Reference [0..*] « Observation|QuestionnaireResponse| FamilyMemberHistory|DiagnosticReport|RiskAssessment| ImagingStudy »FindingSpecific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditionsitem[x] : Type [1..1] « CodeableConcept|Reference(Condition| Observation); Identification of the Condition or diagnosis. (Strength=Example)Condition/Problem/Diagnosis ?? »Which investigations support finding or diagnosiscause : string [0..1]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 outcomesinvestigations[0..*]Specific findings or diagnoses that was considered likely or relevant to ongoing treatmentfinding[0..*]

XML Template

<ClinicalImpression xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business identifier --></identifier>
 <status value="[code]"/><!-- 1..1 draft | completed | entered-in-error -->
 <code><!-- 0..1 CodeableConcept Kind of impression performed --></code>
 <description value="[string]"/><!-- 0..1 Why/how the assessment was performed -->
 <subject><!-- 1..1 Reference(Patient|Group) Patient or group assessed --></subject>
 <assessor><!-- 0..1 Reference(Practitioner) The clinician performing the assessment --></assessor>
 <date value="[dateTime]"/><!-- 0..1 When the assessment was documented -->
 <effective[x]><!-- 0..1 dateTime|Period Time of assessment --></effective[x]>
 <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Encounter or Episode created from --></context>
 <previous><!-- 0..1 Reference(ClinicalImpression) Reference to last assessment --></previous>
 <problem><!-- 0..* Reference(Condition|AllergyIntolerance) Relevant impressions of patient state --></problem>
 <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|QuestionnaireResponse|FamilyMemberHistory|
    DiagnosticReport|RiskAssessment|ImagingStudy) Record of a specific investigation --></item>
 </investigations>
 <protocol value="[uri]"/><!-- 0..* Clinical Protocol followed -->
 <summary value="[string]"/><!-- 0..1 Summary of the assessment -->
 <finding>  <!-- 0..* Possible or likely findings and diagnoses -->
  <item[x]><!-- 1..1 CodeableConcept|Reference(Condition|Observation) What was found --></item[x]>
  <cause value="[string]"/><!-- 0..1 Which investigations support finding -->
 </finding>
 <prognosisCodeableConcept><!-- 0..* CodeableConcept Estimate of likely outcome --></prognosisCodeableConcept>
 <prognosisReference><!-- 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome --></prognosisReference>
 <plan><!-- 0..* Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticRequest|MedicationOrder|NutritionRequest|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) Plan of action after assessment --></plan>
 <action><!-- 0..* Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticRequest|NutritionRequest|SupplyRequest|Appointment) Actions taken during assessment --></action>
 <note><!-- 0..* Annotation Comments made about the ClinicalImpression --></note>
</ClinicalImpression>

JSON Template

{doco
  "resourceType" : "ClinicalImpression",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business identifier
  "status" : "<code>", // R!  draft | completed | entered-in-error
  "code" : { CodeableConcept }, // Kind of impression performed
  "description" : "<string>", // Why/how the assessment was performed
  "subject" : { Reference(Patient|Group) }, // R!  Patient or group assessed
  "assessor" : { Reference(Practitioner) }, // The clinician performing the assessment
  "date" : "<dateTime>", // When the assessment was documented
  // effective[x]: Time of assessment. One of these 2:
  "effectiveDateTime" : "<dateTime>",
  "effectivePeriod" : { Period },
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Encounter or Episode created from
  "previous" : { Reference(ClinicalImpression) }, // Reference to last assessment
  "problem" : [{ Reference(Condition|AllergyIntolerance) }], // Relevant impressions of patient state
  "investigations" : [{ // One or more sets of investigations (signs, symptions, etc.)
    "code" : { CodeableConcept }, // R!  A name/code for the set
    "item" : [{ Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|
    DiagnosticReport|RiskAssessment|ImagingStudy) }] // Record of a specific investigation
  }],
  "protocol" : ["<uri>"], // Clinical Protocol followed
  "summary" : "<string>", // Summary of the assessment
  "finding" : [{ // Possible or likely findings and diagnoses
    // item[x]: What was found. One of these 2:
    "itemCodeableConcept" : { CodeableConcept },
    "itemReference" : { Reference(Condition|Observation) },
    "cause" : "<string>" // Which investigations support finding
  }],
  "prognosisCodeableConcept" : [{ CodeableConcept }], // Estimate of likely outcome
  "prognosisReference" : [{ Reference(RiskAssessment) }], // RiskAssessment expressing likely outcome
  "plan" : [{ Reference(CarePlan|Appointment|CommunicationRequest|
   DeviceUseRequest|DiagnosticRequest|MedicationOrder|NutritionRequest|
   ProcedureRequest|ProcessRequest|ReferralRequest|SupplyRequest|
   VisionPrescription) }], // Plan of action after assessment
  "action" : [{ Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationOrder|DiagnosticRequest|NutritionRequest|SupplyRequest|Appointment) }], // Actions taken during assessment
  "note" : [{ Annotation }] // Comments made about the ClinicalImpression
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClinicalImpression;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClinicalImpression.identifier [ Identifier ], ... ; # 0..* Business identifier
  fhir:ClinicalImpression.status [ code ]; # 1..1 draft | completed | entered-in-error
  fhir:ClinicalImpression.code [ CodeableConcept ]; # 0..1 Kind of impression performed
  fhir:ClinicalImpression.description [ string ]; # 0..1 Why/how the assessment was performed
  fhir:ClinicalImpression.subject [ Reference(Patient|Group) ]; # 1..1 Patient or group assessed
  fhir:ClinicalImpression.assessor [ Reference(Practitioner) ]; # 0..1 The clinician performing the assessment
  fhir:ClinicalImpression.date [ dateTime ]; # 0..1 When the assessment was documented
  # ClinicalImpression.effective[x] : 0..1 Time of assessment. One of these 2
    fhir:ClinicalImpression.effectiveDateTime [ dateTime ]
    fhir:ClinicalImpression.effectivePeriod [ Period ]
  fhir:ClinicalImpression.context [ Reference(Encounter|EpisodeOfCare) ]; # 0..1 Encounter or Episode created from
  fhir:ClinicalImpression.previous [ Reference(ClinicalImpression) ]; # 0..1 Reference to last assessment
  fhir:ClinicalImpression.problem [ Reference(Condition|AllergyIntolerance) ], ... ; # 0..* Relevant impressions of patient state
  fhir:ClinicalImpression.investigations [ # 0..* One or more sets of investigations (signs, symptions, etc.)
    fhir:ClinicalImpression.investigations.code [ CodeableConcept ]; # 1..1 A name/code for the set
    fhir:ClinicalImpression.investigations.item [ Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|DiagnosticReport|
  RiskAssessment|ImagingStudy) ], ... ; # 0..* Record of a specific investigation
  ], ...;
  fhir:ClinicalImpression.protocol [ uri ], ... ; # 0..* Clinical Protocol followed
  fhir:ClinicalImpression.summary [ string ]; # 0..1 Summary of the assessment
  fhir:ClinicalImpression.finding [ # 0..* Possible or likely findings and diagnoses
    # ClinicalImpression.finding.item[x] : 1..1 What was found. One of these 2
      fhir:ClinicalImpression.finding.itemCodeableConcept [ CodeableConcept ]
      fhir:ClinicalImpression.finding.itemReference [ Reference(Condition|Observation) ]
    fhir:ClinicalImpression.finding.cause [ string ]; # 0..1 Which investigations support finding
  ], ...;
  fhir:ClinicalImpression.prognosisCodeableConcept [ CodeableConcept ], ... ; # 0..* Estimate of likely outcome
  fhir:ClinicalImpression.prognosisReference [ Reference(RiskAssessment) ], ... ; # 0..* RiskAssessment expressing likely outcome
  fhir:ClinicalImpression.plan [ Reference(CarePlan|Appointment|CommunicationRequest|DeviceUseRequest|DiagnosticRequest|
  MedicationOrder|NutritionRequest|ProcedureRequest|ProcessRequest|
  ReferralRequest|SupplyRequest|VisionPrescription) ], ... ; # 0..* Plan of action after assessment
  fhir:ClinicalImpression.action [ Reference(ReferralRequest|ProcedureRequest|Procedure|MedicationOrder|DiagnosticRequest|
  NutritionRequest|SupplyRequest|Appointment) ], ... ; # 0..* Actions taken during assessment
  fhir:ClinicalImpression.note [ Annotation ], ... ; # 0..* Comments made about the ClinicalImpression
]

Changes since DSTU2

ClinicalImpression
ClinicalImpression.identifier added
ClinicalImpression.code added
ClinicalImpression.subject Renamed from patient to subject
Add Reference(Group)
ClinicalImpression.effective[x] added
ClinicalImpression.context added
ClinicalImpression.investigations.item Add Reference(RiskAssessment), Add Reference(ImagingStudy)
ClinicalImpression.protocol Max Cardinality changed from 1 to *
ClinicalImpression.finding.item[x] Renamed from item to item[x]
Add Reference(Condition), Add Reference(Observation)
ClinicalImpression.prognosisCodeableConcept added
ClinicalImpression.prognosisReference added
ClinicalImpression.plan Remove Reference(DiagnosticOrder), Remove Reference(NutritionOrder), Remove Reference(Order), Add Reference(DiagnosticRequest), Add Reference(NutritionRequest)
ClinicalImpression.action Remove Reference(DiagnosticOrder), Remove Reference(NutritionOrder), Add Reference(DiagnosticRequest), Add Reference(NutritionRequest)
ClinicalImpression.note added
ClinicalImpression.trigger[x] deleted
ClinicalImpression.resolved deleted
ClinicalImpression.ruledOut deleted
ClinicalImpression.prognosis deleted

See the Full Difference for further information

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle)

9.6.4.1 Terminology Bindings

PathDefinitionTypeReference
ClinicalImpression.status The workflow state of a clinical impression.RequiredClinicalImpressionStatus
ClinicalImpression.code Identifies categories of clinical impressions. This is a place-holder only. It may be removedUnknownNo details provided yet
ClinicalImpression.investigations.code A name/code for a set of investigations.ExampleInvestigation Type
ClinicalImpression.finding.item[x] Identification of the Condition or diagnosis.ExampleCondition/Problem/Diagnosis Codes
ClinicalImpression.prognosisCodeableConcept Prognosis or outlook findingsExampleClinical Impression Prognosis

9.6.5 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 assessmentClinicalImpression.action
(Appointment, ReferralRequest, NutritionRequest, ProcedureRequest, Procedure, MedicationOrder, DiagnosticRequest, SupplyRequest)
assessorreferenceThe clinician performing the assessmentClinicalImpression.assessor
(Practitioner)
contextreferenceEncounter or Episode created fromClinicalImpression.context
(EpisodeOfCare, Encounter)
datedateWhen the assessment was documentedClinicalImpression.date
finding-codetokenWhat was foundClinicalImpression.finding.item[x]
finding-refreferenceWhat was foundClinicalImpression.finding.item[x]
(Condition, Observation)
investigationreferenceRecord of a specific investigationClinicalImpression.investigations.item
(RiskAssessment, FamilyMemberHistory, Observation, DiagnosticReport, ImagingStudy, QuestionnaireResponse)
patientreferencePatient or group assessedClinicalImpression.subject
(Patient)
planreferencePlan of action after assessmentClinicalImpression.plan
(Appointment, ReferralRequest, CarePlan, NutritionRequest, ProcessRequest, VisionPrescription, ProcedureRequest, DeviceUseRequest, MedicationOrder, DiagnosticRequest, CommunicationRequest, SupplyRequest)
previousreferenceReference to last assessmentClinicalImpression.previous
(ClinicalImpression)
problemreferenceRelevant impressions of patient stateClinicalImpression.problem
(Condition, AllergyIntolerance)
statustokendraft | completed | entered-in-errorClinicalImpression.status
subjectreferencePatient or group assessedClinicalImpression.subject
(Group, Patient)