A record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition. Assessments are often 1:1 with a clinical consultation / encounter, but this varies greatly depending on the clinical workflow. This resource is called "ClinicalImpression" rather than "ClinicalAssessment" to avoid confusion with the recording of assessment tools such as Apgar score.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

An Extension

R4: ClinicalImpression.statusReason (new:CodeableConcept)

Element ClinicalImpression.statusReason has a context of ClinicalImpression based on following the parent source element upwards and mapping to ClinicalImpression. Element ClinicalImpression.statusReason has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). This is generally only used for "exception" statuses such as "not-done", "suspended" or "cancelled".

[distinct reason codes for different statuses can be enforced using invariants if they are universal bindings].

R4: ClinicalImpression.supportingInfo (new:Reference(Resource))

Element ClinicalImpression.supportingInfo has a context of ClinicalImpression based on following the parent source element upwards and mapping to ClinicalImpression. Element ClinicalImpression.supportingInfo has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Identifies the workflow status of the assessment.

This element is labeled as a modifier because the status contains the code entered-in-error that marks the clinical impression as not currently valid.

The workflow state of a clinical impression.

The patient or group of individuals assessed as part of this record.

Group is typically for veterinary and/or public health purposes.

R4: ClinicalImpression.statusReason (new:CodeableConcept)

Element ClinicalImpression.statusReason has a context of ClinicalImpression based on following the parent source element upwards and mapping to ClinicalImpression. Element ClinicalImpression.statusReason has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). This is generally only used for "exception" statuses such as "not-done", "suspended" or "cancelled".

[distinct reason codes for different statuses can be enforced using invariants if they are universal bindings].

R4: ClinicalImpression.supportingInfo (new:Reference(Resource))

Element ClinicalImpression.supportingInfo has a context of ClinicalImpression based on following the parent source element upwards and mapping to ClinicalImpression. Element ClinicalImpression.supportingInfo has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

R4: ClinicalImpression.assessor additional types from child elements (display, identifier, reference, type)

Element ClinicalImpression.assessor is mapped to FHIR STU3 element ClinicalImpression.assessor as SourceIsBroaderThanTarget. The mappings for ClinicalImpression.assessor do not cover the following types based on type expansion: display, identifier, reference, type. The standard extension alternate-reference has been mapped as the representation of FHIR R4 element ClinicalImpression.assessor with unmapped reference targets: PractitionerRole.

R4: ClinicalImpression.investigation.item

Element ClinicalImpression.investigation.item is mapped to FHIR STU3 element ClinicalImpression.investigation.item as SourceIsBroaderThanTarget. The standard extension alternate-reference has been mapped as the representation of FHIR R4 element ClinicalImpression.investigation.item with unmapped reference targets: Media. Most investigations are observations of one kind or another but some other specific types of data collection resources can also be used.

R4: ClinicalImpression.finding.itemReference

Element ClinicalImpression.finding.itemReference is mapped to FHIR STU3 element ClinicalImpression.finding.item[x] as RelatedTo. The standard extension alternate-reference has been mapped as the representation of FHIR R4 element ClinicalImpression.finding.itemReference with unmapped reference targets: Media. Source element ClinicalImpression.finding.itemReference has unmapped reference types. While the target element ClinicalImpression.finding.item[x] is a choice type and does not allow extensions, the alternate-reference extension can be applied to Reference values within it.

A record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition. Assessments are often 1:1 with a clinical consultation / encounter, but this varies greatly depending on the clinical workflow. This resource is called "ClinicalImpression" rather than "ClinicalAssessment" to avoid confusion with the recording of assessment tools such as Apgar score.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

An Extension

R4: ClinicalImpression.statusReason (new:CodeableConcept)

Element ClinicalImpression.statusReason has a context of ClinicalImpression based on following the parent source element upwards and mapping to ClinicalImpression. Element ClinicalImpression.statusReason has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element). This is generally only used for "exception" statuses such as "not-done", "suspended" or "cancelled".

[distinct reason codes for different statuses can be enforced using invariants if they are universal bindings].

R4: ClinicalImpression.supportingInfo (new:Reference(Resource))

Element ClinicalImpression.supportingInfo has a context of ClinicalImpression based on following the parent source element upwards and mapping to ClinicalImpression. Element ClinicalImpression.supportingInfo has no mapping targets in FHIR STU3. Typically, this is because the element has been added (is a new element).

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored on.

Identifies the workflow status of the assessment.

This element is labeled as a modifier because the status contains the code entered-in-error that marks the clinical impression as not currently valid.

The workflow state of a clinical impression.

Categorizes the type of clinical assessment performed.

This is present as a place-holder only and may be removed based on feedback/work group opinion.

Identifies categories of clinical impressions. This is a place-holder only. It may be removed

A summary of the context and/or cause of the assessment - why / where was it performed, and what patient events/status prompted it.

The patient or group of individuals assessed as part of this record.

Group is typically for veterinary and/or public health purposes.

The encounter or episode of care this impression was created as part of.

The point in time or period over which the subject was assessed.

This SHOULD be accurate to at least the minute, though some assessments only have a known date.

Indicates when the documentation of the assessment was complete.

The clinician performing the assessment.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

R4: ClinicalImpression.assessor additional types from child elements (display, identifier, reference, type)

Element ClinicalImpression.assessor is mapped to FHIR STU3 element ClinicalImpression.assessor as SourceIsBroaderThanTarget. The mappings for ClinicalImpression.assessor do not cover the following types based on type expansion: display, identifier, reference, type. The standard extension alternate-reference has been mapped as the representation of FHIR R4 element ClinicalImpression.assessor with unmapped reference targets: PractitionerRole.

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Plain text narrative that identifies the resource in addition to the resource reference.

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

A 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.

It is always likely that multiple previous assessments exist for a patient. The point of quoting a previous assessment is that this assessment is relative to it (see resolved).

This a list of the relevant problems/conditions for a patient.

e.g. The patient is a pregnant, and cardiac congestive failure, ‎Adenocarcinoma, and is allergic to penicillin.

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.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A name/code for the group ("set") of investigations. Typically, this will be something like "signs", "symptoms", "clinical", "diagnostic", but the list is not constrained, and others such groups such as (exposure|family|travel|nutitirional) history may be used.

A name/code for a set of investigations.

A record of a specific investigation that was undertaken.

Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

R4: ClinicalImpression.investigation.item

Element ClinicalImpression.investigation.item is mapped to FHIR STU3 element ClinicalImpression.investigation.item as SourceIsBroaderThanTarget. The standard extension alternate-reference has been mapped as the representation of FHIR R4 element ClinicalImpression.investigation.item with unmapped reference targets: Media. Most investigations are observations of one kind or another but some other specific types of data collection resources can also be used.

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

An identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Plain text narrative that identifies the resource in addition to the resource reference.

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.

A text summary of the investigations and the diagnosis.

Specific findings or diagnoses that was considered likely or relevant to ongoing treatment.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Specific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditions.

Identification of the Condition or diagnosis.

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

R4: ClinicalImpression.finding.itemReference

Element ClinicalImpression.finding.itemReference is mapped to FHIR STU3 element ClinicalImpression.finding.item[x] as RelatedTo. The standard extension alternate-reference has been mapped as the representation of FHIR R4 element ClinicalImpression.finding.itemReference with unmapped reference targets: Media. Source element ClinicalImpression.finding.itemReference has unmapped reference types. While the target element ClinicalImpression.finding.item[x] is a choice type and does not allow extensions, the alternate-reference extension can be applied to Reference values within it.

Which investigations support finding or diagnosis.

Estimate of likely outcome.

Prognosis or outlook findings

RiskAssessment expressing likely outcome.

Action taken as part of assessment procedure.

Actions recommended as a result of the impression should not be captured using the 'action' element.

Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear.

Don't use this element for content that should more properly appear as one of the specific elements of the impression.