Name Flags Card. Type Description & Constraints doco
. . ClinicalImpression DomainResource A clinical assessment performed when planning treatments and management strategies for a patient
. . . identifier Σ 0..* Identifier Business identifier
. . . status ?! Σ 1..1 code draft | completed | entered-in-error
ClinicalImpressionStatus ( Required)
. . . code Σ 0..1 CodeableConcept Kind of assessment performed
. . . description Σ 0..1 string Why/how the assessment was performed
. . . subject Σ 1..1 Reference( Patient | Group) Patient or group assessed
. . . assessor Σ 0..1 Reference( Practitioner) The clinician performing the assessment
. . . date Σ 0..1 dateTime When the assessment was documented
. . . effective[x] Σ 0..1 Time of assessment
. . . . effectiveDateTime dateTime
. . . . effectivePeriod Period
. . . context Σ 0..1 Reference( Encounter | EpisodeOfCare) Encounter or Episode created from
. . . previous 0..1 Reference( ClinicalImpression) Reference to last assessment
. . . problem Σ 0..* Reference( Condition | AllergyIntolerance) Relevant impressions of patient state
. . . investigation 0..* BackboneElement One or more sets of investigations (signs, symptions, etc.)
. . . . code 1..1 CodeableConcept A name/code for the set
Investigation Type ( Example)
. . . . item 0..* Reference( Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) Record of a specific investigation
. . . protocol 0..* uri Clinical Protocol followed
. . . summary 0..1 string Summary of the assessment
. . . finding 0..* BackboneElement Possible or likely findings and diagnoses
. . . . item[x] 1..1 What was found
Condition/Problem/Diagnosis Codes ( Example)
. . . . . itemCodeableConcept CodeableConcept
. . . . . itemReference Reference( Condition | Observation)
. . . . basis 0..1 string Which investigations support finding
. . . prognosisCodeableConcept 0..* CodeableConcept Estimate 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..* Annotation Comments made about the ClinicalImpression

doco Documentation for this format