Name Flags Card. Type Description & Constraints doco
. . ClinicalImpression DomainResource A clinical assessment performed when planning treatments and management strategies for a patient
. . . patient Σ 1..1 Reference( Patient) The patient being assessed
. . . assessor Σ 0..1 Reference( Practitioner) The clinician performing the assessment
. . . status ?! Σ 1..1 code in-progress | completed | entered-in-error
ClinicalImpressionStatus ( Required)
. . . date Σ 0..1 dateTime When the assessment occurred
. . . description Σ 0..1 string Why/how the assessment was performed
. . . previous 0..1 Reference( ClinicalImpression) Reference to last assessment
. . . problem Σ 0..* Reference( Condition | AllergyIntolerance) General assessment of patient state
. . . trigger[x] 0..1 Request or event that necessitated this assessment
SNOMED CT Clinical Findings ( Example)
. . . . triggerCodeableConcept CodeableConcept
. . . . triggerReference Reference( Any)
. . . investigations 0..* BackboneElement One or more sets of investigations (signs, symptions, etc.)
. . . . code 1..1 CodeableConcept A name/code for the set
Condition/Diagnosis Certainty ( Example)
. . . . item 0..* Reference( Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport) Record of a specific investigation
. . . protocol 0..1 uri Clinical Protocol followed
. . . summary 0..1 string Summary of the assessment
. . . finding 0..* BackboneElement Possible or likely findings and diagnoses
. . . . item 1..1 CodeableConcept Specific text or code for finding
Condition/Problem/Diagnosis Codes ( Example)
. . . . cause 0..1 string Which investigations support finding
. . . resolved 0..* CodeableConcept Diagnoses/conditions resolved since previous assessment
Condition/Problem/Diagnosis Codes ( Example)
. . . ruledOut 0..* BackboneElement Diagnosis considered not possible
. . . . item 1..1 CodeableConcept Specific text of code for diagnosis
Condition/Problem/Diagnosis Codes ( Example)
. . . . reason 0..1 string Grounds for elimination
. . . prognosis 0..1 string Estimate 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