Name | Flags | Card. | Type |
Description & Constraints
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DomainResource | A clinical assessment performed when planning treatments and management strategies for a patient | ||
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Σ | 1..1 | Reference( Patient) | The patient being assessed |
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Σ | 0..1 | Reference( Practitioner) | The clinician performing the assessment |
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?! Σ | 1..1 | code | in-progress | completed | entered-in-error
ClinicalImpressionStatus ( Required) |
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Σ | 0..1 | dateTime | When the assessment occurred |
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Σ | 0..1 | string | Why/how the assessment was performed |
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0..1 | Reference( ClinicalImpression) | Reference to last assessment | |
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Σ | 0..* | Reference( Condition | AllergyIntolerance) | General assessment of patient state |
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0..1 | Request or event that necessitated this assessment
SNOMED CT Clinical Findings ( Example) |
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CodeableConcept | |||
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Reference( Any) | |||
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0..* | BackboneElement | One or more sets of investigations (signs, symptions, etc.) | |
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1..1 | CodeableConcept | A name/code for the set
Condition/Diagnosis Certainty ( Example) |
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0..* | Reference( Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport) | Record of a specific investigation | |
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0..1 | 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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1..1 | CodeableConcept | Specific text or code for finding
Condition/Problem/Diagnosis Codes ( Example) |
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0..1 | string | Which investigations support finding | |
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0..* | CodeableConcept | Diagnoses/conditions resolved since previous assessment
Condition/Problem/Diagnosis Codes ( Example) |
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0..* | BackboneElement | Diagnosis considered not possible | |
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1..1 | CodeableConcept | Specific text of code for diagnosis
Condition/Problem/Diagnosis Codes ( Example) |
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0..1 | string | Grounds for elimination | |
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0..1 | string | Estimate of likely outcome | |
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0..* | Reference( CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticOrder | MedicationOrder | NutritionOrder | Order | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription) | Plan of action after assessment | |
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0..* | Reference( ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticOrder | NutritionOrder | SupplyRequest | Appointment) | Actions taken during assessment | |
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