This page is part of the FHIR Specification (v4.4.0: R5 Preview #2). 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
Patient Care Work Group | Maturity Level: 0 | Trial Use | Security Category: Patient | Compartments: 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.
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 and the reasoning leading to a differential diagnosis, 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 explicitly reference both care plans (preceding and resulting) and reference a previous impression that this impression follows.
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.
Trial-Use 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 .
ClinicalImpression is the equivalent of the "A" (assessment) in the SOAP note format originally described by Lawrence Weed, MD. It is the outcome of the clinical assessment process. The ClinicalImpression may lead to a statement of a Condition about a patient. 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.
An important background to understanding this resource is the FHIR Confluence 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:
ClinicalImpression 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 itself and Condition.
This resource implements the Event pattern.
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalImpression | TU | DomainResource | A clinical assessment performed when planning treatments and management strategies for a patient Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
identifier | Σ | 0..* | Identifier | Business identifier |
status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown EventStatus (Required) |
statusReason | 0..1 | CodeableConcept | Reason for current status ClinicalImpression Status Reason (Example) | |
description | Σ | 0..1 | string | Why/how the assessment was performed |
subject | Σ | 1..1 | Reference(Patient | Group) | Patient or group assessed |
encounter | Σ | 0..1 | Reference(Encounter) | The Encounter during which this ClinicalImpression was created |
effective[x] | Σ | 0..1 | Time of assessment | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
date | Σ | 0..1 | dateTime | When the assessment was documented |
performer | Σ | 0..1 | Reference(Practitioner | PractitionerRole) | The clinician performing the assessment |
previous | 0..1 | Reference(ClinicalImpression) | Reference to last assessment | |
problem | Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state |
protocol | 0..* | uri | Clinical Protocol followed | |
summary | 0..1 | string | Summary of the assessment | |
finding | 0..* | BackboneElement | Possible or likely findings and diagnoses | |
item | 0..1 | CodeableReference(Condition | Observation | DocumentReference) | What was found Condition/Problem/Diagnosis Codes (Example) | |
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 | |
supportingInfo | 0..* | Reference(Any) | Information supporting the clinical impression | |
note | 0..* | Annotation | Comments made about the ClinicalImpression | |
Documentation for this format |
UML Diagram (Legend)
XML Template
<ClinicalImpression xmlns="http://hl7.org/fhir"> <!-- 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 preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown --> <statusReason><!-- 0..1 CodeableConcept Reason for current status --></statusReason> <description value="[string]"/><!-- 0..1 Why/how the assessment was performed --> <subject><!-- 1..1 Reference(Group|Patient) Patient or group assessed --></subject> <encounter><!-- 0..1 Reference(Encounter) The Encounter during which this ClinicalImpression was created --></encounter> <effective[x]><!-- 0..1 dateTime|Period Time of assessment --></effective[x]> <date value="[dateTime]"/><!-- 0..1 When the assessment was documented --> <performer><!-- 0..1 Reference(Practitioner|PractitionerRole) The clinician performing the assessment --></performer> <previous><!-- 0..1 Reference(ClinicalImpression) Reference to last assessment --></previous> <problem><!-- 0..* Reference(AllergyIntolerance|Condition) Relevant impressions of patient state --></problem> <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><!-- 0..1 CodeableReference(Condition|DocumentReference|Observation) What was found --></item> <basis 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> <supportingInfo><!-- 0..* Reference(Any) Information supporting the clinical impression --></supportingInfo> <note><!-- 0..* Annotation Comments made about the ClinicalImpression --></note> </ClinicalImpression>
JSON Template
{ "resourceType" : "ClinicalImpression", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business identifier "status" : "<code>", // R! preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown "statusReason" : { CodeableConcept }, // Reason for current status "description" : "<string>", // Why/how the assessment was performed "subject" : { Reference(Group|Patient) }, // R! Patient or group assessed "encounter" : { Reference(Encounter) }, // The Encounter during which this ClinicalImpression was created // effective[x]: Time of assessment. One of these 2: "effectiveDateTime" : "<dateTime>", "effectivePeriod" : { Period }, "date" : "<dateTime>", // When the assessment was documented "performer" : { Reference(Practitioner|PractitionerRole) }, // The clinician performing the assessment "previous" : { Reference(ClinicalImpression) }, // Reference to last assessment "problem" : [{ Reference(AllergyIntolerance|Condition) }], // Relevant impressions of patient state "protocol" : ["<uri>"], // Clinical Protocol followed "summary" : "<string>", // Summary of the assessment "finding" : [{ // Possible or likely findings and diagnoses "item" : { CodeableReference(Condition|DocumentReference|Observation) }, // What was found "basis" : "<string>" // Which investigations support finding }], "prognosisCodeableConcept" : [{ CodeableConcept }], // Estimate of likely outcome "prognosisReference" : [{ Reference(RiskAssessment) }], // RiskAssessment expressing likely outcome "supportingInfo" : [{ Reference(Any) }], // Information supporting the clinical impression "note" : [{ Annotation }] // Comments made about the ClinicalImpression }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ 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 preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown fhir:ClinicalImpression.statusReason [ CodeableConcept ]; # 0..1 Reason for current status fhir:ClinicalImpression.description [ string ]; # 0..1 Why/how the assessment was performed fhir:ClinicalImpression.subject [ Reference(Group|Patient) ]; # 1..1 Patient or group assessed fhir:ClinicalImpression.encounter [ Reference(Encounter) ]; # 0..1 The Encounter during which this ClinicalImpression was created # ClinicalImpression.effective[x] : 0..1 Time of assessment. One of these 2 fhir:ClinicalImpression.effectiveDateTime [ dateTime ] fhir:ClinicalImpression.effectivePeriod [ Period ] fhir:ClinicalImpression.date [ dateTime ]; # 0..1 When the assessment was documented fhir:ClinicalImpression.performer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 The clinician performing the assessment fhir:ClinicalImpression.previous [ Reference(ClinicalImpression) ]; # 0..1 Reference to last assessment fhir:ClinicalImpression.problem [ Reference(AllergyIntolerance|Condition) ], ... ; # 0..* Relevant impressions of patient state 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 fhir:ClinicalImpression.finding.item [ CodeableReference(Condition|DocumentReference|Observation) ]; # 0..1 What was found fhir:ClinicalImpression.finding.basis [ 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.supportingInfo [ Reference(Any) ], ... ; # 0..* Information supporting the clinical impression fhir:ClinicalImpression.note [ Annotation ], ... ; # 0..* Comments made about the ClinicalImpression ]
Changes since R3
ClinicalImpression | |
ClinicalImpression.status |
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ClinicalImpression.performer |
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ClinicalImpression.finding.item |
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ClinicalImpression.code |
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ClinicalImpression.assessor |
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ClinicalImpression.investigation |
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ClinicalImpression.finding.itemCodeableConcept |
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ClinicalImpression.finding.itemReference |
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See the Full Difference for further information
This analysis is available as XML or JSON.
See R3 <--> R4 Conversion Maps (status = 1 test that all execute ok. All tests pass round-trip testing and all r3 resources are valid.)
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalImpression | TU | DomainResource | A clinical assessment performed when planning treatments and management strategies for a patient Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
identifier | Σ | 0..* | Identifier | Business identifier |
status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown EventStatus (Required) |
statusReason | 0..1 | CodeableConcept | Reason for current status ClinicalImpression Status Reason (Example) | |
description | Σ | 0..1 | string | Why/how the assessment was performed |
subject | Σ | 1..1 | Reference(Patient | Group) | Patient or group assessed |
encounter | Σ | 0..1 | Reference(Encounter) | The Encounter during which this ClinicalImpression was created |
effective[x] | Σ | 0..1 | Time of assessment | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
date | Σ | 0..1 | dateTime | When the assessment was documented |
performer | Σ | 0..1 | Reference(Practitioner | PractitionerRole) | The clinician performing the assessment |
previous | 0..1 | Reference(ClinicalImpression) | Reference to last assessment | |
problem | Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state |
protocol | 0..* | uri | Clinical Protocol followed | |
summary | 0..1 | string | Summary of the assessment | |
finding | 0..* | BackboneElement | Possible or likely findings and diagnoses | |
item | 0..1 | CodeableReference(Condition | Observation | DocumentReference) | What was found Condition/Problem/Diagnosis Codes (Example) | |
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 | |
supportingInfo | 0..* | Reference(Any) | Information supporting the clinical impression | |
note | 0..* | Annotation | Comments made about the ClinicalImpression | |
Documentation for this format |
XML Template
<ClinicalImpression xmlns="http://hl7.org/fhir"> <!-- 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 preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown --> <statusReason><!-- 0..1 CodeableConcept Reason for current status --></statusReason> <description value="[string]"/><!-- 0..1 Why/how the assessment was performed --> <subject><!-- 1..1 Reference(Group|Patient) Patient or group assessed --></subject> <encounter><!-- 0..1 Reference(Encounter) The Encounter during which this ClinicalImpression was created --></encounter> <effective[x]><!-- 0..1 dateTime|Period Time of assessment --></effective[x]> <date value="[dateTime]"/><!-- 0..1 When the assessment was documented --> <performer><!-- 0..1 Reference(Practitioner|PractitionerRole) The clinician performing the assessment --></performer> <previous><!-- 0..1 Reference(ClinicalImpression) Reference to last assessment --></previous> <problem><!-- 0..* Reference(AllergyIntolerance|Condition) Relevant impressions of patient state --></problem> <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><!-- 0..1 CodeableReference(Condition|DocumentReference|Observation) What was found --></item> <basis 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> <supportingInfo><!-- 0..* Reference(Any) Information supporting the clinical impression --></supportingInfo> <note><!-- 0..* Annotation Comments made about the ClinicalImpression --></note> </ClinicalImpression>
JSON Template
{ "resourceType" : "ClinicalImpression", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business identifier "status" : "<code>", // R! preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown "statusReason" : { CodeableConcept }, // Reason for current status "description" : "<string>", // Why/how the assessment was performed "subject" : { Reference(Group|Patient) }, // R! Patient or group assessed "encounter" : { Reference(Encounter) }, // The Encounter during which this ClinicalImpression was created // effective[x]: Time of assessment. One of these 2: "effectiveDateTime" : "<dateTime>", "effectivePeriod" : { Period }, "date" : "<dateTime>", // When the assessment was documented "performer" : { Reference(Practitioner|PractitionerRole) }, // The clinician performing the assessment "previous" : { Reference(ClinicalImpression) }, // Reference to last assessment "problem" : [{ Reference(AllergyIntolerance|Condition) }], // Relevant impressions of patient state "protocol" : ["<uri>"], // Clinical Protocol followed "summary" : "<string>", // Summary of the assessment "finding" : [{ // Possible or likely findings and diagnoses "item" : { CodeableReference(Condition|DocumentReference|Observation) }, // What was found "basis" : "<string>" // Which investigations support finding }], "prognosisCodeableConcept" : [{ CodeableConcept }], // Estimate of likely outcome "prognosisReference" : [{ Reference(RiskAssessment) }], // RiskAssessment expressing likely outcome "supportingInfo" : [{ Reference(Any) }], // Information supporting the clinical impression "note" : [{ Annotation }] // Comments made about the ClinicalImpression }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ 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 preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown fhir:ClinicalImpression.statusReason [ CodeableConcept ]; # 0..1 Reason for current status fhir:ClinicalImpression.description [ string ]; # 0..1 Why/how the assessment was performed fhir:ClinicalImpression.subject [ Reference(Group|Patient) ]; # 1..1 Patient or group assessed fhir:ClinicalImpression.encounter [ Reference(Encounter) ]; # 0..1 The Encounter during which this ClinicalImpression was created # ClinicalImpression.effective[x] : 0..1 Time of assessment. One of these 2 fhir:ClinicalImpression.effectiveDateTime [ dateTime ] fhir:ClinicalImpression.effectivePeriod [ Period ] fhir:ClinicalImpression.date [ dateTime ]; # 0..1 When the assessment was documented fhir:ClinicalImpression.performer [ Reference(Practitioner|PractitionerRole) ]; # 0..1 The clinician performing the assessment fhir:ClinicalImpression.previous [ Reference(ClinicalImpression) ]; # 0..1 Reference to last assessment fhir:ClinicalImpression.problem [ Reference(AllergyIntolerance|Condition) ], ... ; # 0..* Relevant impressions of patient state 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 fhir:ClinicalImpression.finding.item [ CodeableReference(Condition|DocumentReference|Observation) ]; # 0..1 What was found fhir:ClinicalImpression.finding.basis [ 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.supportingInfo [ Reference(Any) ], ... ; # 0..* Information supporting the clinical impression fhir:ClinicalImpression.note [ Annotation ], ... ; # 0..* Comments made about the ClinicalImpression ]
Changes since Release 3
ClinicalImpression | |
ClinicalImpression.status |
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ClinicalImpression.performer |
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ClinicalImpression.finding.item |
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ClinicalImpression.code |
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ClinicalImpression.assessor |
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ClinicalImpression.investigation |
|
ClinicalImpression.finding.itemCodeableConcept |
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ClinicalImpression.finding.itemReference |
|
See the Full Difference for further information
This analysis is available as XML or JSON.
See R3 <--> R4 Conversion Maps (status = 1 test that all execute ok. All tests pass round-trip testing and all r3 resources are valid.)
See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis a
Path | Definition | Type | Reference |
---|---|---|---|
ClinicalImpression.status | The workflow state of a clinical impression. | Required | EventStatus |
ClinicalImpression.statusReason | Codes identifying the reason for the current state of a clinical impression. | Example | ClinicalImpressionStatusReason |
ClinicalImpression.finding.item | Identification of the Condition or diagnosis. | Example | Condition/Problem/DiagnosisCodes |
ClinicalImpression.prognosisCodeableConcept | Prognosis or outlook findings. | Example | ClinicalImpressionPrognosis |
A known issue exists with circular references between Condition and ClinicalImpression, which is due to the low maturity level of ClinicalImpression. The Patient Care work group intends to address this issue when ClinicalImpression is considered substantially complete and ready for implementation.
Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
Name | Type | Description | Expression | In Common |
date N | date | When the assessment was documented | ClinicalImpression.date | 17 Resources |
encounter | reference | The Encounter during which this ClinicalImpression was created | ClinicalImpression.encounter (Encounter) | |
finding-code D | token | Reference to a concept (by class) | ClinicalImpression.finding.item.concept | |
finding-ref D | reference | Reference to a resource (by instance) | ClinicalImpression.finding.item.reference | |
identifier | token | Business identifier | ClinicalImpression.identifier | |
patient | reference | Patient or group assessed | ClinicalImpression.subject.where(resolve() is Patient) (Patient) | 33 Resources |
performer | reference | The clinician performing the assessment | ClinicalImpression.performer (Practitioner, PractitionerRole) | |
previous | reference | Reference to last assessment | ClinicalImpression.previous (ClinicalImpression) | |
problem | reference | Relevant impressions of patient state | ClinicalImpression.problem (Condition, AllergyIntolerance) | |
status N | token | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown | ClinicalImpression.status | |
subject | reference | Patient or group assessed | ClinicalImpression.subject (Group, Patient) | |
supporting-info | reference | Information supporting the clinical impression | ClinicalImpression.supportingInfo (Any) |