NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression TUDomainResourceA 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 Σ0..*IdentifierBusiness identifier
... status ?!Σ1..1codein-progress | completed | entered-in-error
Clinical Impression Status (Required)
... statusReason 0..1CodeableConceptReason for current status
ClinicalImpressionStatusReason (Example)
... code Σ0..1CodeableConceptKind of assessment performed
ClinicalImpressionCode (Example)
... description Σ0..1stringWhy/how the assessment was performed
... subject Σ1..1Reference(Patient | Group)Patient or group assessed
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... effective[x] Σ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... date Σ0..1dateTimeWhen the assessment was documented
... assessor Σ0..1Reference(Practitioner | PractitionerRole)The clinician performing the assessment
... 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, symptoms, etc.)
.... code 1..1CodeableConceptA name/code for the set
Investigation Type (Example)
.... item 0..*Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)Record of a specific investigation
... protocol 0..*uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... finding 0..*BackboneElementPossible or likely findings and diagnoses
.... itemCodeableConcept 0..1CodeableConceptWhat was found
Condition/Problem/Diagnosis Codes (Example)
.... itemReference 0..1Reference(Condition | Observation | Media)What was found
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate 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..*AnnotationComments made about the ClinicalImpression

doco Documentation for this format