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 assessment 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
... investigation 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)
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate of likely outcome
Clinical Impression Prognosis (Example)
... prognosisReference 0..*Reference(RiskAssessment)RiskAssessment expressing likely outcome
... action 0..*Reference(ReferralRequest | ProcedureRequest | Procedure | MedicationRequest | DiagnosticRequest | Appointment)Action taken as part of assessment procedure
... note 0..*AnnotationComments made about the ClinicalImpression

doco Documentation for this format