DSTU2 Ballot Source
This page is part of the FHIR Specification (v0.5.0: DSTU 2 Ballot 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
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StructureDefinition for clinicalimpression
<StructureDefinition xmlns="http://hl7.org/fhir"> <id value="ClinicalImpression"/> <meta> <lastUpdated value="2015-04-03T14:24:32.000+11:00"/> </meta> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div> </text> <url value="http://hl7.org/fhir/StructureDefinition/ClinicalImpression"/> <name value="ClinicalImpression"/> <publisher value="HL7 FHIR Project (Patient Care)"/> <contact> <telecom> <system value="url"/> <value value="http://hl7.org/fhir"/> </telecom> </contact> <contact> <telecom> <system value="url"/> <value value="http://www.hl7.org/Special/committees/patientcare/index.cfm"/> </telecom> </contact> <description value="Base StructureDefinition for ClinicalImpression Resource"/> <status value="draft"/> <date value="2015-04-03T14:24:32+11:00"/> <mapping> <identity value="rim"/> <uri value="http://hl7.org/v3"/> <name value="RIM"/> </mapping> <type value="resource"/> <abstract value="true"/> <snapshot> <element> <path value="ClinicalImpression"/> <short value="A clinical assessment performed when planning treatments and management strategies for a patient"/> <definition value="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 "ClinicalI mpression" rather than "ClinicalAssessment" to avoid confusion with the recording of assessment tools such as Apgar score."/> <min value="1"/> <max value="1"/> <type> <code value="DomainResource"/> </type> </element> <element> <path value="ClinicalImpression.id"/> <short value="Logical id of this artefact"/> <definition value="The logical id of the resource, as used in the url for the resoure. Once assigned, this value never changes."/> <comments value="The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID."/> <min value="0"/> <max value="1"/> <type> <code value="id"/> </type> </element> <element> <path value="ClinicalImpression.meta"/> <short value="Metadata about the resource"/> <definition value="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."/> <min value="0"/> <max value="1"/> <type> <code value="Meta"/> </type> </element> <element> <path value="ClinicalImpression.implicitRules"/> <short value="A set of rules under which this content was created"/> <definition value="A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content."/> <comments value="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 as much as possible."/> <min value="0"/> <max value="1"/> <type> <code value="uri"/> </type> <isModifier value="true"/> </element> <element> <path value="ClinicalImpression.language"/> <short value="Language of the resource content"/> <definition value="The base language in which the resource is written."/> <comments value="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)."/> <min value="0"/> <max value="1"/> <type> <code value="code"/> </type> <binding> <name value="Language"/> <strength value="required"/> <description value="A human language"/> <valueSetUri value="http://tools.ietf.org/html/bcp47"/> </binding> </element> <element> <path value="ClinicalImpression.text"/> <short value="Text summary of the resource, for human interpretation"/> <definition value="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."/> <comments value="Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative."/> <alias value="narrative"/> <alias value="html"/> <alias value="xhtml"/> <alias value="display"/> <min value="0"/> <max value="1"/> <type> <code value="Narrative"/> </type> <condition value="dom-1"/> <mapping> <identity value="rim"/> <map value="Act.text?"/> </mapping> </element> <element> <path value="ClinicalImpression.contained"/> <short value="Contained, inline Resources"/> <definition value="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."/> <comments value="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."/> <alias value="inline resources"/> <alias value="anonymous resources"/> <alias value="contained resources"/> <min value="0"/> <max value="*"/> <type> <code value="Resource"/> </type> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="ClinicalImpression.extension"/> <short value="Additional Content defined by implementations"/> <definition value="May be used to represent additional information that is not part of the basic definition of the resource. 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."/> <comments value="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."/> <alias value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="ClinicalImpression.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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."/> <comments value="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."/> <alias value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <isModifier value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="ClinicalImpression.patient"/> <short value="The patient being asssesed"/> <definition value="The patient being asssesed."/> <min value="1"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Patient"/> </type> <isSummary value="true"/> </element> <element> <path value="ClinicalImpression.assessor"/> <short value="The clinician performing the assessment"/> <definition value="The clinician performing the assessment."/> <min value="0"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Practitioner"/> </type> <isSummary value="true"/> </element> <element> <path value="ClinicalImpression.status"/> <short value="in-progress | completed | entered-in-error"/> <definition value="Identifies the workflow status of the assessment."/> <min value="1"/> <max value="1"/> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <name value="ClinicalImpressionStatus"/> <strength value="required"/> <description value="The workflow state of a clinical impression"/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/clinical-impression-status"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.date"/> <short value="When the assessment occurred"/> <definition value="The point in time at which the assessment was concluded (not when it was recorded)."/> <comments value="This SHOULD be accurate to at least the minute, though some assessments only have a known date."/> <min value="0"/> <max value="1"/> <type> <code value="dateTime"/> </type> <isSummary value="true"/> </element> <element> <path value="ClinicalImpression.description"/> <short value="Why/how the assessment was performed"/> <definition value="A summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/sstatus prompted it."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> <isSummary value="true"/> </element> <element> <path value="ClinicalImpression.previous"/> <short value="Reference to last assessment"/> <definition value="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."/> <comments value="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)."/> <min value="0"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ClinicalImpression"/> </type> </element> <element> <path value="ClinicalImpression.problem"/> <short value="General assessment of patient state"/> <definition value="This a list of the general problems/conditions for a patient."/> <comments value="e.g. The patient is a pregnant, and cardiac congestive failure, Adenocarcinoma, and is allergic to penicillin."/> <min value="0"/> <max value="*"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Condition"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/AllergyIntolerance"/> </type> <isSummary value="true"/> </element> <element> <path value="ClinicalImpression.trigger[x]"/> <short value="Request or event that necessitated this assessment"/> <definition value="The request or event that necessitated this assessment. This may be a diagnosis, a Care Plan, a Request Referral, or some other resource."/> <min value="0"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <binding> <name value="ClinicalFindings"/> <strength value="example"/> <description value="Clinical Findings that may cause an clinical evaluation"/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/clinical-findings"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.investigations"/> <short value="One or more sets of investigations (signs, symptions, etc)"/> <definition value="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."/> <min value="0"/> <max value="*"/> </element> <element> <path value="ClinicalImpression.investigations.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references)."/> <min value="0"/> <max value="1"/> <type> <code value="id"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="ClinicalImpression.investigations.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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."/> <comments value="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."/> <alias value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="ClinicalImpression.investigations.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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."/> <comments value="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."/> <alias value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <isModifier value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="ClinicalImpression.investigations.code"/> <short value="A name/code for the set"/> <definition value="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|nutitiriona l) history may be used."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="investigationGroupType"/> <strength value="example"/> <description value="A name/code for a set of investigations"/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/investigation-sets"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.investigations.item"/> <short value="Record of a specific investigation"/> <definition value="A record of a specific investigation that was undertaken."/> <comments value="Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used."/> <min value="0"/> <max value="*"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Observation"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/QuestionnaireAnswers"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport"/> </type> </element> <element> <path value="ClinicalImpression.protocol"/> <short value="Clinical Protocol followed"/> <definition value="Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis."/> <min value="0"/> <max value="1"/> <type> <code value="uri"/> </type> </element> <element> <path value="ClinicalImpression.summary"/> <short value="Summary of the assessment"/> <definition value="A text summary of the investigations and the diagnosis."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> </element> <element> <path value="ClinicalImpression.finding"/> <short value="Possible or likely findings and diagnoses"/> <definition value="Specific findings or diagnoses that was considered likely or relevant to ongoing treatment."/> <min value="0"/> <max value="*"/> </element> <element> <path value="ClinicalImpression.finding.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references)."/> <min value="0"/> <max value="1"/> <type> <code value="id"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="ClinicalImpression.finding.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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."/> <comments value="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."/> <alias value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="ClinicalImpression.finding.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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."/> <comments value="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."/> <alias value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <isModifier value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="ClinicalImpression.finding.item"/> <short value="Specific text or code for finding"/> <definition value="Specific text of code for finding or diagnosis."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="ConditionKind"/> <strength value="example"/> <description value="Identification of the Condition or diagnosis."/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/condition-code"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.finding.cause"/> <short value="Which investigations support finding"/> <definition value="Which investigations support finding or diagnosis."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> </element> <element> <path value="ClinicalImpression.resolved"/> <short value="Diagnosies/conditions resolved since previous assessment"/> <definition value="Diagnoses/conditions resolved since the last assessment."/> <min value="0"/> <max value="*"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="ConditionKind"/> <strength value="example"/> <description value="Identification of the Condition or diagnosis."/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/condition-code"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.ruledOut"/> <short value="Diagnosis considered not possible"/> <definition value="Diagnosis considered not possible."/> <min value="0"/> <max value="*"/> </element> <element> <path value="ClinicalImpression.ruledOut.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references)."/> <min value="0"/> <max value="1"/> <type> <code value="id"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="ClinicalImpression.ruledOut.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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."/> <comments value="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."/> <alias value="extensions"/> <alias value="user content"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="ClinicalImpression.ruledOut.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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."/> <comments value="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."/> <alias value="extensions"/> <alias value="user content"/> <alias value="modifiers"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <isModifier value="true"/> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="ClinicalImpression.ruledOut.item"/> <short value="Specific text of code for diagnosis"/> <definition value="Specific text of code for diagnosis."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="ConditionKind"/> <strength value="example"/> <description value="Identification of the Condition or diagnosis."/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/condition-code"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.ruledOut.reason"/> <short value="Grounds for elimination"/> <definition value="Grounds for elimination."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> </element> <element> <path value="ClinicalImpression.prognosis"/> <short value="Estimate of likely outcome"/> <definition value="Estimate of likely outcome."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> </element> <element> <path value="ClinicalImpression.plan"/> <short value="Plan of action after assessment"/> <definition value="Plan of action after assessment."/> <min value="0"/> <max value="*"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/CarePlan"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Appointment"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/CommunicationRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/DeviceUseRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/DiagnosticOrder"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/MedicationPrescription"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/NutritionOrder"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Order"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ProcedureRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ProcessRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ReferralRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Supply"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/VisionPrescription"/> </type> </element> <element> <path value="ClinicalImpression.action"/> <short value="Actions taken during assessment"/> <definition value="Actions taken during assessment."/> <min value="0"/> <max value="*"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ReferralRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ProcedureRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Procedure"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/MedicationPrescription"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/DiagnosticOrder"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/NutritionOrder"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Supply"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Appointment"/> </type> </element> </snapshot> <differential> <element> <path value="ClinicalImpression"/> <short value="A clinical assessment performed when planning treatments and management strategies for a patient"/> <definition value="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 "ClinicalI mpression" rather than "ClinicalAssessment" to avoid confusion with the recording of assessment tools such as Apgar score."/> <min value="1"/> <max value="1"/> <type> <code value="DomainResource"/> </type> </element> <element> <path value="ClinicalImpression.patient"/> <short value="The patient being asssesed"/> <definition value="The patient being asssesed."/> <min value="1"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Patient"/> </type> <isSummary value="true"/> </element> <element> <path value="ClinicalImpression.assessor"/> <short value="The clinician performing the assessment"/> <definition value="The clinician performing the assessment."/> <min value="0"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Practitioner"/> </type> <isSummary value="true"/> </element> <element> <path value="ClinicalImpression.status"/> <short value="in-progress | completed | entered-in-error"/> <definition value="Identifies the workflow status of the assessment."/> <min value="1"/> <max value="1"/> <type> <code value="code"/> </type> <isModifier value="true"/> <isSummary value="true"/> <binding> <name value="ClinicalImpressionStatus"/> <strength value="required"/> <description value="The workflow state of a clinical impression"/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/clinical-impression-status"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.date"/> <short value="When the assessment occurred"/> <definition value="The point in time at which the assessment was concluded (not when it was recorded)."/> <comments value="This SHOULD be accurate to at least the minute, though some assessments only have a known date."/> <min value="0"/> <max value="1"/> <type> <code value="dateTime"/> </type> <isSummary value="true"/> </element> <element> <path value="ClinicalImpression.description"/> <short value="Why/how the assessment was performed"/> <definition value="A summary of the context and/or cause of the assessment - why / where was it peformed, and what patient events/sstatus prompted it."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> <isSummary value="true"/> </element> <element> <path value="ClinicalImpression.previous"/> <short value="Reference to last assessment"/> <definition value="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."/> <comments value="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)."/> <min value="0"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ClinicalImpression"/> </type> </element> <element> <path value="ClinicalImpression.problem"/> <short value="General assessment of patient state"/> <definition value="This a list of the general problems/conditions for a patient."/> <comments value="e.g. The patient is a pregnant, and cardiac congestive failure, Adenocarcinoma, and is allergic to penicillin."/> <min value="0"/> <max value="*"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Condition"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/AllergyIntolerance"/> </type> <isSummary value="true"/> </element> <element> <path value="ClinicalImpression.trigger[x]"/> <short value="Request or event that necessitated this assessment"/> <definition value="The request or event that necessitated this assessment. This may be a diagnosis, a Care Plan, a Request Referral, or some other resource."/> <min value="0"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Resource"/> </type> <binding> <name value="ClinicalFindings"/> <strength value="example"/> <description value="Clinical Findings that may cause an clinical evaluation"/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/clinical-findings"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.investigations"/> <short value="One or more sets of investigations (signs, symptions, etc)"/> <definition value="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."/> <min value="0"/> <max value="*"/> </element> <element> <path value="ClinicalImpression.investigations.code"/> <short value="A name/code for the set"/> <definition value="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|nutitiriona l) history may be used."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="investigationGroupType"/> <strength value="example"/> <description value="A name/code for a set of investigations"/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/investigation-sets"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.investigations.item"/> <short value="Record of a specific investigation"/> <definition value="A record of a specific investigation that was undertaken."/> <comments value="Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used."/> <min value="0"/> <max value="*"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Observation"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/QuestionnaireAnswers"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport"/> </type> </element> <element> <path value="ClinicalImpression.protocol"/> <short value="Clinical Protocol followed"/> <definition value="Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis."/> <min value="0"/> <max value="1"/> <type> <code value="uri"/> </type> </element> <element> <path value="ClinicalImpression.summary"/> <short value="Summary of the assessment"/> <definition value="A text summary of the investigations and the diagnosis."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> </element> <element> <path value="ClinicalImpression.finding"/> <short value="Possible or likely findings and diagnoses"/> <definition value="Specific findings or diagnoses that was considered likely or relevant to ongoing treatment."/> <min value="0"/> <max value="*"/> </element> <element> <path value="ClinicalImpression.finding.item"/> <short value="Specific text or code for finding"/> <definition value="Specific text of code for finding or diagnosis."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="ConditionKind"/> <strength value="example"/> <description value="Identification of the Condition or diagnosis."/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/condition-code"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.finding.cause"/> <short value="Which investigations support finding"/> <definition value="Which investigations support finding or diagnosis."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> </element> <element> <path value="ClinicalImpression.resolved"/> <short value="Diagnosies/conditions resolved since previous assessment"/> <definition value="Diagnoses/conditions resolved since the last assessment."/> <min value="0"/> <max value="*"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="ConditionKind"/> <strength value="example"/> <description value="Identification of the Condition or diagnosis."/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/condition-code"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.ruledOut"/> <short value="Diagnosis considered not possible"/> <definition value="Diagnosis considered not possible."/> <min value="0"/> <max value="*"/> </element> <element> <path value="ClinicalImpression.ruledOut.item"/> <short value="Specific text of code for diagnosis"/> <definition value="Specific text of code for diagnosis."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="ConditionKind"/> <strength value="example"/> <description value="Identification of the Condition or diagnosis."/> <valueSetReference> <reference value="http://hl7.org/fhir/vs/condition-code"/> </valueSetReference> </binding> </element> <element> <path value="ClinicalImpression.ruledOut.reason"/> <short value="Grounds for elimination"/> <definition value="Grounds for elimination."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> </element> <element> <path value="ClinicalImpression.prognosis"/> <short value="Estimate of likely outcome"/> <definition value="Estimate of likely outcome."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> </element> <element> <path value="ClinicalImpression.plan"/> <short value="Plan of action after assessment"/> <definition value="Plan of action after assessment."/> <min value="0"/> <max value="*"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/CarePlan"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Appointment"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/CommunicationRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/DeviceUseRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/DiagnosticOrder"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/MedicationPrescription"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/NutritionOrder"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Order"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ProcedureRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ProcessRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ReferralRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Supply"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/VisionPrescription"/> </type> </element> <element> <path value="ClinicalImpression.action"/> <short value="Actions taken during assessment"/> <definition value="Actions taken during assessment."/> <min value="0"/> <max value="*"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ReferralRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/ProcedureRequest"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Procedure"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/MedicationPrescription"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/DiagnosticOrder"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/NutritionOrder"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Supply"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/StructureDefinition/Appointment"/> </type> </element> </differential> </StructureDefinition>
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
© HL7.org 2011+. FHIR DSTU (v0.5.0-5149) generated on Fri, Apr 3, 2015 14:30+1100.
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