- A clinical assessment performed when planning treatments and management strategies for a patient Base StructureDefinition for ClinicalImpression Resource
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Key: = Must support, = QICore-defined extension, = Is-Modifier
Field Card. Type and Description 
action 0..*List<ReferralRequest | ProcedureRequest | Procedure | MedicationOrder | DiagnosticRequest | NutritionRequest | SupplyRequest | Appointment>Actions taken during assessment.assessor 0..1PractitionerThe clinician performing the assessment.code 0..1ConceptCategorizes the type of clinical impression performed.(Example)
context 0..1Encounter | EpisodeOfCareThe encounter or episode of care this impression was created as part of.date 0..1DateTimeIndicates when the documentation of the assessment was complete.description 0..1StringA summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/status prompted it.effective[x] 0..1DateTime | interval<DateTime>The point in time or period over which the subject was assessed.finding 0..*List<Finding>Specific findings or diagnoses that was considered likely or relevant to ongoing treatment.identifier 0..*List<Identifier>A unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored on.investigations 0..*List<Investigations>One or more sets of investigations (signs, symptions, etc.). The actual grouping of investigations vary greatly depending on the type and context of the assessment. These investigations may include data generated during the assessment process, or data previously generated and recorded that is pertinent to the outcomes.note 0..*List<Annotation>Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear.plan 0..*List<CarePlan | Appointment | CommunicationRequest | DeviceUseRequest | DiagnosticRequest | MedicationOrder | NutritionRequest | ProcedureRequest | ProcessRequest | ReferralRequest | SupplyRequest | VisionPrescription>Plan of action after assessment.previous 0..1ClinicalImpressionA reference to the last assesment that was conducted bon 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 changes.problem 0..*List<Condition | AllergyIntolerance>This a list of the relevant problems/conditions for a patient.prognosisCodeableConcept 0..*List<Concept>Estimate of likely outcome.Binding: Clinical Impression Prognosis (Example)
prognosisReference 0..*List<RiskAssessment>RiskAssessment expressing likely outcome.protocol 0..*List<Uri>Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.status 1..1codeIdentifies the workflow status of the assessment.Binding: ClinicalImpressionStatus (Required)
subject 1..1Patient | GroupThe patient or group of individuals assessed as part of this record.summary 0..1StringA text summary of the investigations and the diagnosis.Key: = Must support, = QICore-defined extension, = Is-Modifier
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