Name | Flags | Card. | Type |
Description & Constraints
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DomainResource | A clinical assessment performed when planning treatments and management strategies for a patient | ||
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Σ | 0..* | Identifier | Business identifier |
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?! Σ | 1..1 | code | draft | completed | entered-in-error
ClinicalImpressionStatus ( Required) |
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Σ | 0..1 | CodeableConcept | Kind of assessment performed |
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Σ | 0..1 | string | Why/how the assessment was performed |
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Σ | 1..1 | Reference( Patient | Group) | Patient or group assessed |
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Σ | 0..1 | Reference( Practitioner) | The clinician performing the assessment |
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Σ | 0..1 | dateTime | When the assessment was documented |
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Σ | 0..1 | Time of assessment | |
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dateTime | |||
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Period | |||
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Σ | 0..1 | Reference( Encounter | EpisodeOfCare) | Encounter or Episode created from |
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0..1 | Reference( ClinicalImpression) | Reference to last assessment | |
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Σ | 0..* | Reference( Condition | AllergyIntolerance) | Relevant impressions of patient state |
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0..* | BackboneElement | One or more sets of investigations (signs, symptions, etc.) | |
|
1..1 | CodeableConcept | A name/code for the set
Investigation Type ( Example) |
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0..* | Reference( Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) | Record of a specific investigation | |
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0..* | uri | Clinical Protocol followed | |
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0..1 | string | Summary of the assessment | |
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0..* | BackboneElement | Possible or likely findings and diagnoses | |
|
1..1 | What was found
Condition/Problem/Diagnosis Codes ( Example) |
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CodeableConcept | |||
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Reference( Condition | Observation) | |||
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0..1 | string | Which investigations support finding | |
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0..* | CodeableConcept | Estimate of likely outcome
Clinical Impression Prognosis ( Example) |
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0..* | Reference( RiskAssessment) | RiskAssessment expressing likely outcome | |
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0..* | Reference( ReferralRequest | ProcedureRequest | Procedure | MedicationRequest | DiagnosticRequest | Appointment) | Action taken as part of assessment procedure | |
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0..* | Annotation | Comments made about the ClinicalImpression | |
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