FHIR Clinical Guidelines (v1.0.0) (STU1)
This page is part of the Clinical Guidelines (v1.0.0: STU 1) based on FHIR R4. This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
The official URL for this profile is:
http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-clinicalimpression
CPG Clinical Impression captures clinician judgement at any particular point, and related to the case features and pathway, strategies, and recommendations.
This profile builds on ClinicalImpression.
This profile was published on Thu Jun 06 00:00:00 UTC 2019 as a draft by Health Level Seven, Inc. - CDS WG.
Description of Profiles, Differentials, and Snapshots.
Summary
Must-Support: 11 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
  cpg-impressionFor | S | 0..1 | Reference(CPGCase) | Which case URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor |
 identifier | S | 0..* | Identifier | Business identifier |
| status | S | 1..1 | code | in-progress | completed | entered-in-error |
| code | S | 0..1 | CodeableConcept | Kind of assessment performed |
| description | S | 0..1 | string | Why/how the assessment was performed |
 subject | S | 1..1 | Reference(CPGPatient) | Patient or group assessed |
| encounter | S | 0..1 | Reference(CPGEncounter) | Encounter created as part of |
| effective[x] | S | 0..1 | dateTime, Period | Time of assessment |
| date | S | 0..1 | dateTime | When the assessment was documented |
| assessor | S | 0..1 | Reference(CPGPractitioner | CPGPractitionerRole) | The clinician performing the assessment |
 protocol | S | 0..* | uri | Clinical Protocol followed |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
 id | Σ | 0..1 | string | Logical id of this artifact |
 meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| cpg-impressionFor | S | 0..1 | Reference(CPGCase) | Which case URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣ | 0..* | Identifier | Business identifier |
| status | ?!SΣ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. |
| statusReason | 0..1 | CodeableConcept | Reason for current status Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression. | |
| code | SΣ | 0..1 | CodeableConcept | Kind of assessment performed Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. |
| description | SΣ | 0..1 | string | Why/how the assessment was performed |
| subject | SΣ | 1..1 | Reference(CPGPatient) | Patient or group assessed |
| encounter | SΣ | 0..1 | Reference(CPGEncounter) | Encounter created as part of |
 effective[x] | SΣ | 0..1 | Time of assessment | |
 effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| date | SΣ | 0..1 | dateTime | When the assessment was documented |
| assessor | SΣ | 0..1 | Reference(CPGPractitioner | CPGPractitionerRole) | The clinician performing the assessment |
| previous | 0..1 | Reference(ClinicalImpression) | Reference to last assessment | |
| problem | Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state |
| investigation | 0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. | |
| item | 0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) | Record of a specific investigation | |
| protocol | S | 0..* | uri | Clinical Protocol followed |
| summary | 0..1 | string | Summary of the assessment | |
| finding | 0..* | BackboneElement | Possible or likely findings and diagnoses | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemCodeableConcept | 0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| itemReference | 0..1 | Reference(Condition | Observation | Media) | What was found | |
| basis | 0..1 | string | Which investigations support finding | |
| prognosisCodeableConcept | 0..* | CodeableConcept | Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings. | |
| prognosisReference | 0..* | Reference(RiskAssessment) | RiskAssessment expressing likely outcome | |
| supportingInfo | 0..* | Reference(Resource) | Information supporting the clinical impression | |
| note | 0..* | Annotation | Comments made about the ClinicalImpression | |
| Documentation for this format | ||||
Summary
Must-Support: 11 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
| cpg-impressionFor | S | 0..1 | Reference(CPGCase) | Which case URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor |
| identifier | S | 0..* | Identifier | Business identifier |
| status | S | 1..1 | code | in-progress | completed | entered-in-error |
| code | S | 0..1 | CodeableConcept | Kind of assessment performed |
| description | S | 0..1 | string | Why/how the assessment was performed |
| subject | S | 1..1 | Reference(CPGPatient) | Patient or group assessed |
| encounter | S | 0..1 | Reference(CPGEncounter) | Encounter created as part of |
| effective[x] | S | 0..1 | dateTime, Period | Time of assessment |
| date | S | 0..1 | dateTime | When the assessment was documented |
| assessor | S | 0..1 | Reference(CPGPractitioner | CPGPractitionerRole) | The clinician performing the assessment |
| protocol | S | 0..* | uri | Clinical Protocol followed |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| cpg-impressionFor | S | 0..1 | Reference(CPGCase) | Which case URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-impressionFor |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SΣ | 0..* | Identifier | Business identifier |
| status | ?!SΣ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. |
| statusReason | 0..1 | CodeableConcept | Reason for current status Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression. | |
| code | SΣ | 0..1 | CodeableConcept | Kind of assessment performed Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed. |
| description | SΣ | 0..1 | string | Why/how the assessment was performed |
| subject | SΣ | 1..1 | Reference(CPGPatient) | Patient or group assessed |
| encounter | SΣ | 0..1 | Reference(CPGEncounter) | Encounter created as part of |
| effective[x] | SΣ | 0..1 | Time of assessment | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| date | SΣ | 0..1 | dateTime | When the assessment was documented |
| assessor | SΣ | 0..1 | Reference(CPGPractitioner | CPGPractitionerRole) | The clinician performing the assessment |
| previous | 0..1 | Reference(ClinicalImpression) | Reference to last assessment | |
| problem | Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state |
| investigation | 0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | CodeableConcept | A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations. | |
| item | 0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) | Record of a specific investigation | |
| protocol | S | 0..* | uri | Clinical Protocol followed |
| summary | 0..1 | string | Summary of the assessment | |
| finding | 0..* | BackboneElement | Possible or likely findings and diagnoses | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemCodeableConcept | 0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |
| itemReference | 0..1 | Reference(Condition | Observation | Media) | What was found | |
| basis | 0..1 | string | Which investigations support finding | |
| prognosisCodeableConcept | 0..* | CodeableConcept | Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings. | |
| prognosisReference | 0..* | Reference(RiskAssessment) | RiskAssessment expressing likely outcome | |
| supportingInfo | 0..* | Reference(Resource) | Information supporting the clinical impression | |
| note | 0..* | Annotation | Comments made about the ClinicalImpression | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClinicalImpression.language | preferred | CommonLanguages Max Binding: AllLanguages |
| ClinicalImpression.status | required | ClinicalImpressionStatus |
| ClinicalImpression.statusReason | example | |
| ClinicalImpression.code | example | |
| ClinicalImpression.investigation.code | example | InvestigationType |
| ClinicalImpression.finding.itemCodeableConcept | example | Condition/Problem/DiagnosisCodes |
| ClinicalImpression.prognosisCodeableConcept | example | ClinicalImpressionPrognosis |
| Id | Path | Details | Requirements |
| dom-2 | ClinicalImpression | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | ClinicalImpression | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | ClinicalImpression | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | ClinicalImpression | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | ClinicalImpression.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | ClinicalImpression.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | ClinicalImpression.extension:impressionFor | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | ClinicalImpression.extension:impressionFor | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | ClinicalImpression.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | ClinicalImpression.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | ClinicalImpression.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.statusReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.description | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.effective[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.date | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.assessor | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.previous | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.problem | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.investigation | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.investigation.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | ClinicalImpression.investigation.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | ClinicalImpression.investigation.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | ClinicalImpression.investigation.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | ClinicalImpression.investigation.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.investigation.item | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.protocol | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.summary | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.finding | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.finding.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | ClinicalImpression.finding.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | ClinicalImpression.finding.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | ClinicalImpression.finding.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | ClinicalImpression.finding.itemCodeableConcept | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.finding.itemReference | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.finding.basis | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.prognosisCodeableConcept | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.prognosisReference | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.supportingInfo | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | ClinicalImpression.note | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
© HL7.org (Clinical Decision Support WG). hl7.fhir.uv.cpg#1.0.0 based on FHIR v4.0.1. Generated 2021-02-11.
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