Name | Flags | Card. | Type |
Description & Constraints
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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 |
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Σ | 0..* | Identifier | Business identifier
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?! Σ | 1..1 | code | in-progress | completed | entered-in-error
Clinical Impression Status ( Required) |
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0..1 | CodeableConcept | Reason for current status
ClinicalImpressionStatusReason ( Example) |
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Σ | 0..1 | CodeableConcept | Kind of assessment performed
ClinicalImpressionCode ( Example) |
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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( Encounter) | Encounter created as part of |
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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 | dateTime | When the assessment was documented |
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Σ | 0..1 | Reference( Practitioner | PractitionerRole) | The clinician performing the assessment |
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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, symptoms, etc.)
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1..1 | CodeableConcept | A name/code for the set
Investigation Type ( Example) |
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0..* | Reference( Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) | 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
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0..1 | CodeableConcept | What was found
Condition/Problem/Diagnosis Codes ( Example) |
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0..1 | Reference( Condition | Observation | Media) | What was found | |
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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( Any) | Information supporting the clinical impression
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0..* | Annotation | Comments made about the ClinicalImpression
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