R4 Draft for Comment
Clinical SummaryThis page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4 R3 R2
| Patient Care Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Encounter, Patient, Practitioner |
StructureDefinition for clinicalimpression
{
"resourceType": "StructureDefinition",
"id": "ClinicalImpression",
"meta": {
"lastUpdated": "2017-12-20T15:52:34.818+11:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 0
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "pc"
}
],
"url": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression",
"name": "ClinicalImpression",
"status": "draft",
"date": "2017-12-20T15:52:34+11:00",
"publisher": "Health Level Seven International (Patient Care)",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/patientcare/index.cfm"
}
]
}
],
"description": "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.",
"fhirVersion": "3.2.0",
"mapping": [
{
"identity": "workflow",
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern"
},
{
"identity": "v2",
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping"
},
{
"identity": "w5",
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping"
},
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM Mapping"
}
],
"kind": "resource",
"abstract": false,
"type": "ClinicalImpression",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"derivation": "specialization",
"snapshot": {
"element": [
{
"id": "ClinicalImpression",
"path": "ClinicalImpression",
"short": "A clinical assessment performed when planning treatments and management strategies for a patient",
"definition": "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.",
"min": 0,
"max": "*",
"constraint": [
{
"key": "dom-2",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression": "contained.contained.empty()",
"xpath": "not(parent::f:contained and f:contained)",
"source": "DomainResource"
},
{
"key": "dom-1",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"expression": "contained.text.empty()",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource"
},
{
"key": "dom-4",
"severity": "error",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "DomainResource"
},
{
"key": "dom-3",
"severity": "error",
"human": "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",
"expression": "contained.all(('#'+id in %resource.descendants().reference) or descendants().where(reference = '#').exists())",
"xpath": "not(exists(for $contained in f:contained return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::reference[@value='#'])]))",
"source": "DomainResource"
}
],
"mapping": [
{
"identity": "rim",
"map": "Entity. Role, or Act"
},
{
"identity": "workflow",
"map": "Event"
},
{
"identity": "v2",
"map": "Partial mapping for problem evaluation"
},
{
"identity": "w5",
"map": "clinical.general"
}
]
},
{
"id": "ClinicalImpression.id",
"path": "ClinicalImpression.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"id": "ClinicalImpression.meta",
"path": "ClinicalImpression.meta",
"short": "Metadata about the resource",
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.meta",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"id": "ClinicalImpression.implicitRules",
"path": "ClinicalImpression.implicitRules",
"short": "A set of rules under which this content was created",
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.",
"comment": "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. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.implicitRules",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"id": "ClinicalImpression.language",
"path": "ClinicalImpression.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comment": "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": 0,
"max": "1",
"base": {
"path": "Resource.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "ClinicalImpression.text",
"path": "ClinicalImpression.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "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.",
"comment": "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.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "DomainResource.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"id": "ClinicalImpression.contained",
"path": "ClinicalImpression.contained",
"short": "Contained, inline Resources",
"definition": "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.",
"comment": "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": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClinicalImpression.extension",
"path": "ClinicalImpression.extension",
"short": "Additional Content defined by implementations",
"definition": "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.",
"comment": "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": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClinicalImpression.modifierExtension",
"path": "ClinicalImpression.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "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.",
"comment": "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": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClinicalImpression.identifier",
"path": "ClinicalImpression.identifier",
"short": "Business identifier",
"definition": "A unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored on.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
},
{
"identity": "v2",
"map": "PID-3"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "ClinicalImpression.status",
"path": "ClinicalImpression.status",
"short": "draft | completed | entered-in-error",
"definition": "Identifies the workflow status of the assessment.",
"comment": "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.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClinicalImpressionStatus"
}
],
"strength": "required",
"description": "The workflow state of a clinical impression.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/clinical-impression-status"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
},
{
"identity": "v2",
"map": "PRB-14"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "ClinicalImpression.code",
"path": "ClinicalImpression.code",
"short": "Kind of assessment performed",
"definition": "Categorizes the type of clinical assessment performed.",
"comment": "This is present as a place-holder only and may be removed based on feedback/work group opinion.",
"alias": [
"type"
],
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClinicalImpressionCode"
}
],
"strength": "example",
"description": "Identifies categories of clinical impressions. This is a place-holder only. It may be removed"
},
"mapping": [
{
"identity": "workflow",
"map": "Event.code"
},
{
"identity": "w5",
"map": "FiveWs.what[x]"
},
{
"identity": "w5",
"map": "what"
}
]
},
{
"id": "ClinicalImpression.description",
"path": "ClinicalImpression.description",
"short": "Why/how the assessment was performed",
"definition": "A summary of the context and/or cause of the assessment - why / where was it performed, and what patient events/status prompted it.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true
},
{
"id": "ClinicalImpression.subject",
"path": "ClinicalImpression.subject",
"short": "Patient or group assessed",
"definition": "The patient or group of individuals assessed as part of this record.",
"requirements": "Group is typically for veterinary and/or public health purposes.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Group"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.subject"
},
{
"identity": "w5",
"map": "FiveWs.subject[x]"
},
{
"identity": "v2",
"map": "PID-3"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "ClinicalImpression.context",
"path": "ClinicalImpression.context",
"short": "Encounter or Episode created from",
"definition": "The encounter or episode of care this impression was created as part of.",
"alias": [
"encounter"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Encounter"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/EpisodeOfCare"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.context"
},
{
"identity": "w5",
"map": "FiveWs.context"
},
{
"identity": "w5",
"map": "context"
}
]
},
{
"id": "ClinicalImpression.effective[x]",
"path": "ClinicalImpression.effective[x]",
"short": "Time of assessment",
"definition": "The point in time or period over which the subject was assessed.",
"comment": "This SHOULD be accurate to at least the minute, though some assessments only have a known date.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
},
{
"code": "Period"
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
},
{
"identity": "v2",
"map": "PRB-2"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "ClinicalImpression.date",
"path": "ClinicalImpression.date",
"short": "When the assessment was documented",
"definition": "Indicates when the documentation of the assessment was complete.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.recorded"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "ClinicalImpression.assessor",
"path": "ClinicalImpression.assessor",
"short": "The clinician performing the assessment",
"definition": "The clinician performing the assessment.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.performer.actor"
},
{
"identity": "w5",
"map": "FiveWs.author"
},
{
"identity": "v2",
"map": "ROL-4"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "ClinicalImpression.previous",
"path": "ClinicalImpression.previous",
"short": "Reference to last assessment",
"definition": "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.",
"comment": "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": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression"
}
]
},
{
"id": "ClinicalImpression.problem",
"path": "ClinicalImpression.problem",
"short": "Relevant impressions of patient state",
"definition": "This a list of the relevant problems/conditions for a patient.",
"comment": "e.g. The patient is a pregnant, and cardiac congestive failure, Adenocarcinoma, and is allergic to penicillin.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/AllergyIntolerance"
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.why[x]"
},
{
"identity": "v2",
"map": "PRB-3 / IAM-7"
},
{
"identity": "w5",
"map": "why"
}
]
},
{
"id": "ClinicalImpression.investigation",
"path": "ClinicalImpression.investigation",
"short": "One or more sets of investigations (signs, symptions, etc.)",
"definition": "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": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ClinicalImpression.investigation.id",
"path": "ClinicalImpression.investigation.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClinicalImpression.investigation.extension",
"path": "ClinicalImpression.investigation.extension",
"short": "Additional Content defined by implementations",
"definition": "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.",
"comment": "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": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClinicalImpression.investigation.modifierExtension",
"path": "ClinicalImpression.investigation.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "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.",
"comment": "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": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClinicalImpression.investigation.code",
"path": "ClinicalImpression.investigation.code",
"short": "A name/code for the set",
"definition": "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.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InvestigationGroupType"
}
],
"strength": "example",
"description": "A name/code for a set of investigations.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/investigation-sets"
}
}
},
{
"id": "ClinicalImpression.investigation.item",
"path": "ClinicalImpression.investigation.item",
"short": "Record of a specific investigation",
"definition": "A record of a specific investigation that was undertaken.",
"comment": "Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Observation"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RiskAssessment"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ImagingStudy"
}
],
"mapping": [
{
"identity": "v2",
"map": "OBX-21"
}
]
},
{
"id": "ClinicalImpression.protocol",
"path": "ClinicalImpression.protocol",
"short": "Clinical Protocol followed",
"definition": "Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.",
"min": 0,
"max": "*",
"type": [
{
"code": "uri"
}
]
},
{
"id": "ClinicalImpression.summary",
"path": "ClinicalImpression.summary",
"short": "Summary of the assessment",
"definition": "A text summary of the investigations and the diagnosis.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "v2",
"map": "OBX"
}
]
},
{
"id": "ClinicalImpression.finding",
"path": "ClinicalImpression.finding",
"short": "Possible or likely findings and diagnoses",
"definition": "Specific findings or diagnoses that was considered likely or relevant to ongoing treatment.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ClinicalImpression.finding.id",
"path": "ClinicalImpression.finding.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClinicalImpression.finding.extension",
"path": "ClinicalImpression.finding.extension",
"short": "Additional Content defined by implementations",
"definition": "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.",
"comment": "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": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClinicalImpression.finding.modifierExtension",
"path": "ClinicalImpression.finding.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "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.",
"comment": "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": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClinicalImpression.finding.item[x]",
"path": "ClinicalImpression.finding.item[x]",
"short": "What was found",
"definition": "Specific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditions.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Observation"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ConditionKind"
}
],
"strength": "example",
"description": "Identification of the Condition or diagnosis.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-code"
}
},
"mapping": [
{
"identity": "v2",
"map": "OBX"
}
]
},
{
"id": "ClinicalImpression.finding.basis",
"path": "ClinicalImpression.finding.basis",
"short": "Which investigations support finding",
"definition": "Which investigations support finding or diagnosis.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ClinicalImpression.prognosisCodeableConcept",
"path": "ClinicalImpression.prognosisCodeableConcept",
"short": "Estimate of likely outcome",
"definition": "Estimate of likely outcome.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClinicalImpressionPrognosis"
}
],
"strength": "example",
"description": "Prognosis or outlook findings",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis"
}
},
"mapping": [
{
"identity": "v2",
"map": "PRB-22"
}
]
},
{
"id": "ClinicalImpression.prognosisReference",
"path": "ClinicalImpression.prognosisReference",
"short": "RiskAssessment expressing likely outcome",
"definition": "RiskAssessment expressing likely outcome.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RiskAssessment"
}
]
},
{
"id": "ClinicalImpression.action",
"path": "ClinicalImpression.action",
"short": "Action taken as part of assessment procedure",
"definition": "Action taken as part of assessment procedure.",
"comment": "Actions recommended as a result of the impression should not be captured using the 'action' element.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ServiceRequest"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Appointment"
}
]
},
{
"id": "ClinicalImpression.note",
"path": "ClinicalImpression.note",
"short": "Comments made about the ClinicalImpression",
"definition": "Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear.",
"comment": "Don't use this element for content that should more properly appear as one of the specific elements of the impression.",
"min": 0,
"max": "*",
"type": [
{
"code": "Annotation"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.note"
}
]
}
]
},
"differential": {
"element": [
{
"id": "ClinicalImpression",
"path": "ClinicalImpression",
"short": "A clinical assessment performed when planning treatments and management strategies for a patient",
"definition": "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.",
"min": 0,
"max": "*",
"mapping": [
{
"identity": "workflow",
"map": "Event"
},
{
"identity": "v2",
"map": "Partial mapping for problem evaluation"
},
{
"identity": "w5",
"map": "clinical.general"
}
]
},
{
"id": "ClinicalImpression.identifier",
"path": "ClinicalImpression.identifier",
"short": "Business identifier",
"definition": "A unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored on.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
},
{
"identity": "v2",
"map": "PID-3"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "ClinicalImpression.status",
"path": "ClinicalImpression.status",
"short": "draft | completed | entered-in-error",
"definition": "Identifies the workflow status of the assessment.",
"comment": "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.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClinicalImpressionStatus"
}
],
"strength": "required",
"description": "The workflow state of a clinical impression.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/clinical-impression-status"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
},
{
"identity": "v2",
"map": "PRB-14"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "ClinicalImpression.code",
"path": "ClinicalImpression.code",
"short": "Kind of assessment performed",
"definition": "Categorizes the type of clinical assessment performed.",
"comment": "This is present as a place-holder only and may be removed based on feedback/work group opinion.",
"alias": [
"type"
],
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClinicalImpressionCode"
}
],
"strength": "example",
"description": "Identifies categories of clinical impressions. This is a place-holder only. It may be removed"
},
"mapping": [
{
"identity": "workflow",
"map": "Event.code"
},
{
"identity": "w5",
"map": "FiveWs.what[x]"
},
{
"identity": "w5",
"map": "what"
}
]
},
{
"id": "ClinicalImpression.description",
"path": "ClinicalImpression.description",
"short": "Why/how the assessment was performed",
"definition": "A summary of the context and/or cause of the assessment - why / where was it performed, and what patient events/status prompted it.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"isSummary": true
},
{
"id": "ClinicalImpression.subject",
"path": "ClinicalImpression.subject",
"short": "Patient or group assessed",
"definition": "The patient or group of individuals assessed as part of this record.",
"requirements": "Group is typically for veterinary and/or public health purposes.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Group"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.subject"
},
{
"identity": "w5",
"map": "FiveWs.subject[x]"
},
{
"identity": "v2",
"map": "PID-3"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "ClinicalImpression.context",
"path": "ClinicalImpression.context",
"short": "Encounter or Episode created from",
"definition": "The encounter or episode of care this impression was created as part of.",
"alias": [
"encounter"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Encounter"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/EpisodeOfCare"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.context"
},
{
"identity": "w5",
"map": "FiveWs.context"
},
{
"identity": "w5",
"map": "context"
}
]
},
{
"id": "ClinicalImpression.effective[x]",
"path": "ClinicalImpression.effective[x]",
"short": "Time of assessment",
"definition": "The point in time or period over which the subject was assessed.",
"comment": "This SHOULD be accurate to at least the minute, though some assessments only have a known date.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
},
{
"code": "Period"
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.done[x]"
},
{
"identity": "v2",
"map": "PRB-2"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "ClinicalImpression.date",
"path": "ClinicalImpression.date",
"short": "When the assessment was documented",
"definition": "Indicates when the documentation of the assessment was complete.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.recorded"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "ClinicalImpression.assessor",
"path": "ClinicalImpression.assessor",
"short": "The clinician performing the assessment",
"definition": "The clinician performing the assessment.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"isSummary": true,
"mapping": [
{
"identity": "workflow",
"map": "Event.performer.actor"
},
{
"identity": "w5",
"map": "FiveWs.author"
},
{
"identity": "v2",
"map": "ROL-4"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "ClinicalImpression.previous",
"path": "ClinicalImpression.previous",
"short": "Reference to last assessment",
"definition": "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.",
"comment": "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": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression"
}
]
},
{
"id": "ClinicalImpression.problem",
"path": "ClinicalImpression.problem",
"short": "Relevant impressions of patient state",
"definition": "This a list of the relevant problems/conditions for a patient.",
"comment": "e.g. The patient is a pregnant, and cardiac congestive failure, Adenocarcinoma, and is allergic to penicillin.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/AllergyIntolerance"
}
],
"isSummary": true,
"mapping": [
{
"identity": "w5",
"map": "FiveWs.why[x]"
},
{
"identity": "v2",
"map": "PRB-3 / IAM-7"
},
{
"identity": "w5",
"map": "why"
}
]
},
{
"id": "ClinicalImpression.investigation",
"path": "ClinicalImpression.investigation",
"short": "One or more sets of investigations (signs, symptions, etc.)",
"definition": "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": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ClinicalImpression.investigation.code",
"path": "ClinicalImpression.investigation.code",
"short": "A name/code for the set",
"definition": "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.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "InvestigationGroupType"
}
],
"strength": "example",
"description": "A name/code for a set of investigations.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/investigation-sets"
}
}
},
{
"id": "ClinicalImpression.investigation.item",
"path": "ClinicalImpression.investigation.item",
"short": "Record of a specific investigation",
"definition": "A record of a specific investigation that was undertaken.",
"comment": "Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Observation"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RiskAssessment"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ImagingStudy"
}
],
"mapping": [
{
"identity": "v2",
"map": "OBX-21"
}
]
},
{
"id": "ClinicalImpression.protocol",
"path": "ClinicalImpression.protocol",
"short": "Clinical Protocol followed",
"definition": "Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.",
"min": 0,
"max": "*",
"type": [
{
"code": "uri"
}
]
},
{
"id": "ClinicalImpression.summary",
"path": "ClinicalImpression.summary",
"short": "Summary of the assessment",
"definition": "A text summary of the investigations and the diagnosis.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "v2",
"map": "OBX"
}
]
},
{
"id": "ClinicalImpression.finding",
"path": "ClinicalImpression.finding",
"short": "Possible or likely findings and diagnoses",
"definition": "Specific findings or diagnoses that was considered likely or relevant to ongoing treatment.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ClinicalImpression.finding.item[x]",
"path": "ClinicalImpression.finding.item[x]",
"short": "What was found",
"definition": "Specific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditions.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Observation"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ConditionKind"
}
],
"strength": "example",
"description": "Identification of the Condition or diagnosis.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-code"
}
},
"mapping": [
{
"identity": "v2",
"map": "OBX"
}
]
},
{
"id": "ClinicalImpression.finding.basis",
"path": "ClinicalImpression.finding.basis",
"short": "Which investigations support finding",
"definition": "Which investigations support finding or diagnosis.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ClinicalImpression.prognosisCodeableConcept",
"path": "ClinicalImpression.prognosisCodeableConcept",
"short": "Estimate of likely outcome",
"definition": "Estimate of likely outcome.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClinicalImpressionPrognosis"
}
],
"strength": "example",
"description": "Prognosis or outlook findings",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis"
}
},
"mapping": [
{
"identity": "v2",
"map": "PRB-22"
}
]
},
{
"id": "ClinicalImpression.prognosisReference",
"path": "ClinicalImpression.prognosisReference",
"short": "RiskAssessment expressing likely outcome",
"definition": "RiskAssessment expressing likely outcome.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RiskAssessment"
}
]
},
{
"id": "ClinicalImpression.action",
"path": "ClinicalImpression.action",
"short": "Action taken as part of assessment procedure",
"definition": "Action taken as part of assessment procedure.",
"comment": "Actions recommended as a result of the impression should not be captured using the 'action' element.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ServiceRequest"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
},
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Appointment"
}
]
},
{
"id": "ClinicalImpression.note",
"path": "ClinicalImpression.note",
"short": "Comments made about the ClinicalImpression",
"definition": "Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear.",
"comment": "Don't use this element for content that should more properly appear as one of the specific elements of the impression.",
"min": 0,
"max": "*",
"type": [
{
"code": "Annotation"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.note"
}
]
}
]
}
}
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 Release 4 Draft for Comment (Jan-2018 v3.2.0-12885) generated on Wed, Dec 20, 2017 15:56+1100. QA Page
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