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 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.

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.

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.

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.

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 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.

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.

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

Which investigations support finding or diagnosis.

Estimate of likely outcome.

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.