NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression DomainResourceA clinical assessment performed when planning treatments and management strategies for a patient
... patient Σ1..1Reference(Patient)The patient being assessed
... assessor Σ0..1Reference(Practitioner)The clinician performing the assessment
... status ?! Σ1..1codein-progress | completed | entered-in-error
ClinicalImpressionStatus (Required)
... date Σ0..1dateTimeWhen the assessment occurred
... description Σ0..1stringWhy/how the assessment was performed
... previous 0..1Reference(ClinicalImpression)Reference to last assessment
... problem Σ0..*Reference(Condition | AllergyIntolerance)General assessment of patient state
... trigger[x] 0..1Request or event that necessitated this assessment
SNOMED CT Clinical Findings (Example)
.... triggerCodeableConceptCodeableConcept
.... triggerReferenceReference(Any)
... investigations 0..*BackboneElementOne or more sets of investigations (signs, symptions, etc.)
.... code 1..1CodeableConceptA name/code for the set
Condition/Diagnosis Certainty (Example)
.... item 0..*Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport)Record of a specific investigation
... protocol 0..1uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... finding 0..*BackboneElementPossible or likely findings and diagnoses
.... item 1..1CodeableConceptSpecific text or code for finding
Condition/Problem/Diagnosis Codes (Example)
.... cause 0..1stringWhich investigations support finding
... resolved 0..*CodeableConceptDiagnoses/conditions resolved since previous assessment
Condition/Problem/Diagnosis Codes (Example)
... ruledOut 0..*BackboneElementDiagnosis considered not possible
.... item 1..1CodeableConceptSpecific text of code for diagnosis
Condition/Problem/Diagnosis Codes (Example)
.... reason 0..1stringGrounds for elimination
... prognosis 0..1stringEstimate of likely outcome
... plan 0..*Reference(CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription)Plan of action after assessment
... action 0..*Reference(ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticOrder | NutritionOrder | SupplyRequest | Appointment)Actions taken during assessment

doco Documentation for this format