R6 Ballot (3rd Draft)

This page is part of the FHIR Specification v6.0.0-ballot3: Release 6 Ballot (3rd Draft) (see Ballot Notes). The current version is 5.0.0. For a full list of available versions, see the Directory of published versions

9.8 Resource ClinicalAssessment - Content

Patient Care icon Work GroupMaturity Level: 1 Trial UseSecurity Category: Patient Compartments: Encounter, Group, 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 "ClinicalAssessment" rather than "ClinicalAssessment" to avoid confusion with the recording of assessment tools such as Apgar score.

9.8.1 Scope and Usage

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 assessments are recorded. Some clinical assessments simply result in an assessment 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 assessment can explicitly reference both care plans (preceding and resulting) and reference a previous assessment that this assessment follows.

An assessment is a clinical summation of information and/or an opinion formed, which is the outcome of the clinical assessment process. The ClinicalAssessment 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.

Note to Implementers: 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 assessment 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 assessment? (e.g. for a 'provisional' assessment, 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 assessment is needed. Both answers to the previous questions and ongoing discussions around revisions to the care plan will influence the design of clinical assessment
  • Should prognosis be represented, and if so, how much structure should it have?
  • Should an assessment reference other assessments 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 icon.

9.8.2 Boundaries and Relationships

ClinicalAssessment 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 ClinicalAssessment 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 ClinicalAssessment resource is about; assessment tools such as Apgar are represented as Observations, and Questionnaires may be used to help generate these. Clinical assessments may refer to these assessment tools as one of the investigations that was performed during the assessment process.

9.8.3 Background and Context

An important background to understanding this resource is the FHIR Confluence page for clinical assessment icon. In particular, the storyboards there drove the design of the resource, and will be the basis for all examples created.

PLANNED CHANGE:

ClinicalAssessment 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.

9.8.4 References to this Resource

9.8.5 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalAssessment 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
Binding: EventStatus (Required)
... statusReason 0..1 CodeableConcept Reason for current status
Binding: ClinicalAssessment Status Reason (Example)
... subject Σ 1..1 Reference(Patient | Group) Patient or group assessed
... encounter Σ 0..1 Reference(Encounter) The Encounter during which this ClinicalAssessment 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(ClinicalAssessment) Reference to last assessment
... problem Σ 0..* Reference(Condition | AllergyIntolerance) Relevant assessments of patient state

... changePattern 0..1 CodeableConcept Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change
Binding: ClinicalAssessment Change Pattern (Example)
... protocol 0..* uri Clinical Protocol followed

... summary 0..1 markdown Text summary of the assessment
... finding 0..* BackboneElement Possible or likely findings and diagnoses

.... item 0..1 CodeableReference(Condition | Observation | DocumentReference) What was found
Binding: Condition/Problem/Diagnosis Codes (Example)
.... basis 0..1 string Which investigations support finding
... prognosisCodeableConcept 0..* CodeableConcept Estimate of likely outcome
Binding: Clinical assessment Prognosis (Example)

... prognosisReference 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome

... supportingInfo 0..* Reference(Any) Information supporting the clinical assessment

... note 0..* Annotation Comments made about the ClinicalAssessment


doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

ClinicalAssessment (DomainResource)Business identifiers assigned to this clinical assessment by the performer or other systems which remain constant as the resource is updated and propagates from server to serveridentifier : Identifier [0..*]Identifies the workflow status of the assessment (this element modifies the meaning of other elements)status : code [1..1] « null (Strength=Required)EventStatus! »Captures the reason for the current state of the ClinicalAssessmentstatusReason : CodeableConcept [0..1] « null (Strength=Example) ClinicalAssessmentStatusReason?? »A summary of the context and/or cause of the assessment - why / where it was performed, and what patient events/status prompted itdescription : string [0..1]The patient or group of individuals assessed as part of this recordsubject : Reference [1..1] « Patient|Group »The Encounter during which this ClinicalAssessment was created or to which the creation of this record is tightly associatedencounter : Reference [0..1] « Encounter »The point in time or period over which the subject was assessedeffective[x] : DataType [0..1] « dateTime|Period »Indicates when the documentation of the assessment was completedate : dateTime [0..1]The clinician performing the assessmentperformer : Reference [0..1] « Practitioner|PractitionerRole »A reference to the last assessment that was conducted on this patient. Assessments are often/usually ongoing in nature; a care provider (practitioner or team) will make new assessments on an ongoing basis as new data arises or the patient's conditions changesprevious : Reference [0..1] « ClinicalAssessment »A list of the relevant problems/conditions for a patientproblem : Reference [0..*] « Condition|AllergyIntolerance »Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change. It is a subjective assessment of the direction of the changechangePattern : CodeableConcept [0..1] « null (Strength=Example) ClinicalAssessmentChangePatter?? »Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosisprotocol : uri [0..*]A text summary of the investigations and the diagnosissummary : markdown [0..1]Estimate of likely outcomeprognosisCodeableConcept : CodeableConcept [0..*] « null (Strength=Example) ClinicalAssessmentPrognosis?? »RiskAssessment expressing likely outcomeprognosisReference : Reference [0..*] « RiskAssessment »Information supporting the clinical assessment, which can contain investigation resultssupportingInfo : Reference [0..*] « Any »Commentary about the assessment, typically recorded after the assessment itself was made, though supplemental notes by the original author could also appearnote : Annotation [0..*]FindingSpecific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditionsitem : CodeableReference [0..1] « Condition|Observation| DocumentReference; null (Strength=Example)ConditionProblemDiagnosisCodes?? »Which investigations support finding or diagnosisbasis : string [0..1]Specific findings or diagnoses that were considered likely or relevant to ongoing treatmentfinding[0..*]

XML Template

<ClinicalAssessment xmlns="http://hl7.org/fhir"> doco
 <!-- 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 ClinicalAssessment 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(ClinicalAssessment) Reference to last assessment --></previous>
 <problem><!-- 0..* Reference(AllergyIntolerance|Condition) Relevant assessments of patient state --></problem>
 <changePattern><!-- 0..1 CodeableConcept Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change --></changePattern>
 <protocol value="[uri]"/><!-- 0..* Clinical Protocol followed -->
 <summary value="[markdown]"/><!-- 0..1 Text 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 assessment --></supportingInfo>
 <note><!-- 0..* Annotation Comments made about the ClinicalAssessment --></note>
</ClinicalAssessment>

JSON Template

{doco
  "resourceType" : "ClinicalAssessment",
  // 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 ClinicalAssessment 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(ClinicalAssessment) }, // Reference to last assessment
  "problem" : [{ Reference(AllergyIntolerance|Condition) }], // Relevant assessments of patient state
  "changePattern" : { CodeableConcept }, // Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change
  "protocol" : ["<uri>"], // Clinical Protocol followed
  "summary" : "<markdown>", // Text 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 assessment
  "note" : [{ Annotation }] // Comments made about the ClinicalAssessment
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClinicalAssessment;
  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:identifier  ( [ Identifier ] ... ) ; # 0..* Business identifier
  fhir:status [ code ] ; # 1..1 preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
  fhir:statusReason [ CodeableConcept ] ; # 0..1 Reason for current status
  fhir:description [ string ] ; # 0..1 Why/how the assessment was performed
  fhir:subject [ Reference(Group|Patient) ] ; # 1..1 Patient or group assessed
  fhir:encounter [ Reference(Encounter) ] ; # 0..1 The Encounter during which this ClinicalAssessment was created
  # effective[x] : 0..1 Time of assessment. One of these 2
    fhir:effective [  a fhir:dateTime ; dateTime ]
    fhir:effective [  a fhir:Period ; Period ]
  fhir:date [ dateTime ] ; # 0..1 When the assessment was documented
  fhir:performer [ Reference(Practitioner|PractitionerRole) ] ; # 0..1 The clinician performing the assessment
  fhir:previous [ Reference(ClinicalAssessment) ] ; # 0..1 Reference to last assessment
  fhir:problem  ( [ Reference(AllergyIntolerance|Condition) ] ... ) ; # 0..* Relevant assessments of patient state
  fhir:changePattern [ CodeableConcept ] ; # 0..1 Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change
  fhir:protocol  ( [ uri ] ... ) ; # 0..* Clinical Protocol followed
  fhir:summary [ markdown ] ; # 0..1 Text summary of the assessment
  fhir:finding ( [ # 0..* Possible or likely findings and diagnoses
    fhir:item [ CodeableReference(Condition|DocumentReference|Observation) ] ; # 0..1 What was found
    fhir:basis [ string ] ; # 0..1 Which investigations support finding
  ] ... ) ;
  fhir:prognosisCodeableConcept  ( [ CodeableConcept ] ... ) ; # 0..* Estimate of likely outcome
  fhir:prognosisReference  ( [ Reference(RiskAssessment) ] ... ) ; # 0..* RiskAssessment expressing likely outcome
  fhir:supportingInfo  ( [ Reference(Any) ] ... ) ; # 0..* Information supporting the clinical assessment
  fhir:note  ( [ Annotation ] ... ) ; # 0..* Comments made about the ClinicalAssessment
]

Changes from both R4 and R4B

This resource did not exist in Release R4

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalAssessment 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
Binding: EventStatus (Required)
... statusReason 0..1 CodeableConcept Reason for current status
Binding: ClinicalAssessment Status Reason (Example)
... subject Σ 1..1 Reference(Patient | Group) Patient or group assessed
... encounter Σ 0..1 Reference(Encounter) The Encounter during which this ClinicalAssessment 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(ClinicalAssessment) Reference to last assessment
... problem Σ 0..* Reference(Condition | AllergyIntolerance) Relevant assessments of patient state

... changePattern 0..1 CodeableConcept Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change
Binding: ClinicalAssessment Change Pattern (Example)
... protocol 0..* uri Clinical Protocol followed

... summary 0..1 markdown Text summary of the assessment
... finding 0..* BackboneElement Possible or likely findings and diagnoses

.... item 0..1 CodeableReference(Condition | Observation | DocumentReference) What was found
Binding: Condition/Problem/Diagnosis Codes (Example)
.... basis 0..1 string Which investigations support finding
... prognosisCodeableConcept 0..* CodeableConcept Estimate of likely outcome
Binding: Clinical assessment Prognosis (Example)

... prognosisReference 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome

... supportingInfo 0..* Reference(Any) Information supporting the clinical assessment

... note 0..* Annotation Comments made about the ClinicalAssessment


doco Documentation for this format icon

See the Extensions for this resource

UML Diagram (Legend)

ClinicalAssessment (DomainResource)Business identifiers assigned to this clinical assessment by the performer or other systems which remain constant as the resource is updated and propagates from server to serveridentifier : Identifier [0..*]Identifies the workflow status of the assessment (this element modifies the meaning of other elements)status : code [1..1] « null (Strength=Required)EventStatus! »Captures the reason for the current state of the ClinicalAssessmentstatusReason : CodeableConcept [0..1] « null (Strength=Example) ClinicalAssessmentStatusReason?? »A summary of the context and/or cause of the assessment - why / where it was performed, and what patient events/status prompted itdescription : string [0..1]The patient or group of individuals assessed as part of this recordsubject : Reference [1..1] « Patient|Group »The Encounter during which this ClinicalAssessment was created or to which the creation of this record is tightly associatedencounter : Reference [0..1] « Encounter »The point in time or period over which the subject was assessedeffective[x] : DataType [0..1] « dateTime|Period »Indicates when the documentation of the assessment was completedate : dateTime [0..1]The clinician performing the assessmentperformer : Reference [0..1] « Practitioner|PractitionerRole »A reference to the last assessment that was conducted on this patient. Assessments are often/usually ongoing in nature; a care provider (practitioner or team) will make new assessments on an ongoing basis as new data arises or the patient's conditions changesprevious : Reference [0..1] « ClinicalAssessment »A list of the relevant problems/conditions for a patientproblem : Reference [0..*] « Condition|AllergyIntolerance »Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change. It is a subjective assessment of the direction of the changechangePattern : CodeableConcept [0..1] « null (Strength=Example) ClinicalAssessmentChangePatter?? »Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosisprotocol : uri [0..*]A text summary of the investigations and the diagnosissummary : markdown [0..1]Estimate of likely outcomeprognosisCodeableConcept : CodeableConcept [0..*] « null (Strength=Example) ClinicalAssessmentPrognosis?? »RiskAssessment expressing likely outcomeprognosisReference : Reference [0..*] « RiskAssessment »Information supporting the clinical assessment, which can contain investigation resultssupportingInfo : Reference [0..*] « Any »Commentary about the assessment, typically recorded after the assessment itself was made, though supplemental notes by the original author could also appearnote : Annotation [0..*]FindingSpecific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditionsitem : CodeableReference [0..1] « Condition|Observation| DocumentReference; null (Strength=Example)ConditionProblemDiagnosisCodes?? »Which investigations support finding or diagnosisbasis : string [0..1]Specific findings or diagnoses that were considered likely or relevant to ongoing treatmentfinding[0..*]

XML Template

<ClinicalAssessment xmlns="http://hl7.org/fhir"> doco
 <!-- 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 ClinicalAssessment 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(ClinicalAssessment) Reference to last assessment --></previous>
 <problem><!-- 0..* Reference(AllergyIntolerance|Condition) Relevant assessments of patient state --></problem>
 <changePattern><!-- 0..1 CodeableConcept Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change --></changePattern>
 <protocol value="[uri]"/><!-- 0..* Clinical Protocol followed -->
 <summary value="[markdown]"/><!-- 0..1 Text 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 assessment --></supportingInfo>
 <note><!-- 0..* Annotation Comments made about the ClinicalAssessment --></note>
</ClinicalAssessment>

JSON Template

{doco
  "resourceType" : "ClinicalAssessment",
  // 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 ClinicalAssessment 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(ClinicalAssessment) }, // Reference to last assessment
  "problem" : [{ Reference(AllergyIntolerance|Condition) }], // Relevant assessments of patient state
  "changePattern" : { CodeableConcept }, // Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change
  "protocol" : ["<uri>"], // Clinical Protocol followed
  "summary" : "<markdown>", // Text 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 assessment
  "note" : [{ Annotation }] // Comments made about the ClinicalAssessment
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClinicalAssessment;
  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:identifier  ( [ Identifier ] ... ) ; # 0..* Business identifier
  fhir:status [ code ] ; # 1..1 preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
  fhir:statusReason [ CodeableConcept ] ; # 0..1 Reason for current status
  fhir:description [ string ] ; # 0..1 Why/how the assessment was performed
  fhir:subject [ Reference(Group|Patient) ] ; # 1..1 Patient or group assessed
  fhir:encounter [ Reference(Encounter) ] ; # 0..1 The Encounter during which this ClinicalAssessment was created
  # effective[x] : 0..1 Time of assessment. One of these 2
    fhir:effective [  a fhir:dateTime ; dateTime ]
    fhir:effective [  a fhir:Period ; Period ]
  fhir:date [ dateTime ] ; # 0..1 When the assessment was documented
  fhir:performer [ Reference(Practitioner|PractitionerRole) ] ; # 0..1 The clinician performing the assessment
  fhir:previous [ Reference(ClinicalAssessment) ] ; # 0..1 Reference to last assessment
  fhir:problem  ( [ Reference(AllergyIntolerance|Condition) ] ... ) ; # 0..* Relevant assessments of patient state
  fhir:changePattern [ CodeableConcept ] ; # 0..1 Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change
  fhir:protocol  ( [ uri ] ... ) ; # 0..* Clinical Protocol followed
  fhir:summary [ markdown ] ; # 0..1 Text summary of the assessment
  fhir:finding ( [ # 0..* Possible or likely findings and diagnoses
    fhir:item [ CodeableReference(Condition|DocumentReference|Observation) ] ; # 0..1 What was found
    fhir:basis [ string ] ; # 0..1 Which investigations support finding
  ] ... ) ;
  fhir:prognosisCodeableConcept  ( [ CodeableConcept ] ... ) ; # 0..* Estimate of likely outcome
  fhir:prognosisReference  ( [ Reference(RiskAssessment) ] ... ) ; # 0..* RiskAssessment expressing likely outcome
  fhir:supportingInfo  ( [ Reference(Any) ] ... ) ; # 0..* Information supporting the clinical assessment
  fhir:note  ( [ Annotation ] ... ) ; # 0..* Comments made about the ClinicalAssessment
]

Changes from both R4 and R4B

This resource did not exist in Release R4

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

9.8.5.1 Terminology Bindings

Path ValueSet Type Documentation
ClinicalAssessment.status EventStatus Required

Codes identifying the lifecycle stage of an event.
ClinicalAssessment.statusReason ClinicalAssessmentStatusReason Example

Example codes indicating the reason why a ClinicalAssessment is on hold or stopped. Note that these are in no way complete and might not even be appropriate for some uses.
ClinicalAssessment.changePattern ClinicalAssessmentChangePatter Example

Example codes indicating the change pattern of a ClinicalAssessment. Note that these are in no way complete and might not even be appropriate for some uses.
ClinicalAssessment.finding.item ConditionProblemDiagnosisCodes Example

Example value set for Condition/Problem/Diagnosis codes.
ClinicalAssessment.prognosisCodeableConcept ClinicalAssessmentPrognosis Example

Example value set for clinical assessment prognosis.

9.8.5.2 Known Issue

A known issue exists with circular references between Condition and ClinicalAssessment, which is due to the low maturity level of ClinicalAssessment. The Patient Care work group intends to address this issue when ClinicalAssessment is considered substantially complete and ready for implementation.

9.8.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to 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 date When the assessment was documented ClinicalAssessment.date
encounter reference The Encounter during which this ClinicalAssessment was created ClinicalAssessment.encounter
(Encounter)
finding-code token Reference to a concept (by class) ClinicalAssessment.finding.item.concept
finding-ref reference Reference to a resource (by instance) ClinicalAssessment.finding.item.reference
identifier token Business identifier ClinicalAssessment.identifier
patient reference Patient assessed ClinicalAssessment.subject.where(resolve() is Patient)
(Patient)
performer reference The clinician performing the assessment ClinicalAssessment.performer
(Practitioner, PractitionerRole)
previous reference Reference to last assessment ClinicalAssessment.previous
(ClinicalAssessment)
problem reference Relevant impressions of patient state ClinicalAssessment.problem
(Condition, AllergyIntolerance)
status token preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown ClinicalAssessment.status
subject reference Patient or group assessed ClinicalAssessment.subject
(Group, Patient)
supporting-info reference Information supporting the clinical impression ClinicalAssessment.supportingInfo
(Any)