The ClinicalImpression sets minimum expectations for the ClinicalImpression Resource to record, search, and fetch clnical impressions that apply to a patient. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile. In addition to the requirements set forth in ClinicalImpression this derived profile is designed to add requirements to the following elements:

• MCCClinicalImpressionClinicalImpression.extension:resource-pertainsToGoal (Must Support) to encourage linking a goal to the clinical impression hopes to facilitate and/or to encourage systems to be able to receive and understand a goal linkage if present.
• MCCClinicalImpression.subject is set to us-core-patient and set to must support
• MCCClinicalImpression.effective is must support
• MCCClinicalImpression.problem is required and must be supported

Comments are welcome with respect to the pragmatic use of the “Must Support” rules defined on these elements.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from ClinicalImpression

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
resource-pertainsToGoal	S	0..*	Reference(Goal)	The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
changePattern		0..1	CodeableConcept	Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change URL: http://hl7.org/fhir/us/mcc/StructureDefinition/changePattern
subject	S	1..1	Reference(US Core Patient Profile)	Patient or group assessed
type
value		0..1	uri	Primitive value for uri
effective[x]	S	0..1	dateTime, Period	Time of assessment
problem	S	1..*	Reference(Condition | AllergyIntolerance)	Relevant impressions of patient state
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
resource-pertainsToGoal	S	0..*	Reference(Goal)	The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
changePattern		0..1	CodeableConcept	Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change URL: http://hl7.org/fhir/us/mcc/StructureDefinition/changePattern
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
subject	SΣ	1..1	Reference(US Core Patient Profile)	Patient or group assessed
effective[x]	SΣ	0..1		Time of assessment
effectiveDateTime			dateTime
effectivePeriod			Period
problem	SΣ	1..*	Reference(Condition | AllergyIntolerance)	Relevant impressions of patient state
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClinicalImpression.status	required	ClinicalImpressionStatus

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClinicalImpression	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClinicalImpression	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClinicalImpression	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
resource-pertainsToGoal	S	0..*	Reference(Goal)	The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
changePattern		0..1	CodeableConcept	Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change URL: http://hl7.org/fhir/us/mcc/StructureDefinition/changePattern
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business identifier
status	?!Σ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
statusReason		0..1	CodeableConcept	Reason for current status Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.
code	Σ	0..1	CodeableConcept	Kind of assessment performed Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
description	Σ	0..1	string	Why/how the assessment was performed
subject	SΣ	1..1	Reference(US Core Patient Profile)	Patient or group assessed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional content defined by implementations
value		0..1	uri	Primitive value for uri
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
effective[x]	SΣ	0..1		Time of assessment
effectiveDateTime			dateTime
effectivePeriod			Period
date	Σ	0..1	dateTime	When the assessment was documented
assessor	Σ	0..1	Reference(Practitioner | PractitionerRole)	The clinician performing the assessment
previous		0..1	Reference(ClinicalImpression)	Reference to last assessment
problem	SΣ	1..*	Reference(Condition | AllergyIntolerance)	Relevant impressions of patient state
investigation		0..*	BackboneElement	One or more sets of investigations (signs, symptoms, etc.)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations.
item		0..*	Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)	Record of a specific investigation
protocol		0..*	uri	Clinical Protocol followed
summary		0..1	string	Summary of the assessment
finding		0..*	BackboneElement	Possible or likely findings and diagnoses
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemCodeableConcept		0..1	CodeableConcept	What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
itemReference		0..1	Reference(Condition | Observation | Media)	What was found
basis		0..1	string	Which investigations support finding
prognosisCodeableConcept		0..*	CodeableConcept	Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
prognosisReference		0..*	Reference(RiskAssessment)	RiskAssessment expressing likely outcome
supportingInfo		0..*	Reference(Resource)	Information supporting the clinical impression
note		0..*	Annotation	Comments made about the ClinicalImpression
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClinicalImpression.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClinicalImpression.status	required	ClinicalImpressionStatus
ClinicalImpression.statusReason	example
ClinicalImpression.code	example
ClinicalImpression.subject.type	extensible	ResourceType
ClinicalImpression.investigation.code	example	InvestigationType
ClinicalImpression.finding.itemCodeableConcept	example	Condition/Problem/DiagnosisCodes
ClinicalImpression.prognosisCodeableConcept	example	ClinicalImpressionPrognosis

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from ClinicalImpression

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
resource-pertainsToGoal	S	0..*	Reference(Goal)	The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
changePattern		0..1	CodeableConcept	Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change URL: http://hl7.org/fhir/us/mcc/StructureDefinition/changePattern
subject	S	1..1	Reference(US Core Patient Profile)	Patient or group assessed
type
value		0..1	uri	Primitive value for uri
effective[x]	S	0..1	dateTime, Period	Time of assessment
problem	S	1..*	Reference(Condition | AllergyIntolerance)	Relevant impressions of patient state
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
resource-pertainsToGoal	S	0..*	Reference(Goal)	The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
changePattern		0..1	CodeableConcept	Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change URL: http://hl7.org/fhir/us/mcc/StructureDefinition/changePattern
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
subject	SΣ	1..1	Reference(US Core Patient Profile)	Patient or group assessed
effective[x]	SΣ	0..1		Time of assessment
effectiveDateTime			dateTime
effectivePeriod			Period
problem	SΣ	1..*	Reference(Condition | AllergyIntolerance)	Relevant impressions of patient state
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClinicalImpression.status	required	ClinicalImpressionStatus

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClinicalImpression	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClinicalImpression	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClinicalImpression	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
resource-pertainsToGoal	S	0..*	Reference(Goal)	The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
changePattern		0..1	CodeableConcept	Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change URL: http://hl7.org/fhir/us/mcc/StructureDefinition/changePattern
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business identifier
status	?!Σ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
statusReason		0..1	CodeableConcept	Reason for current status Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.
code	Σ	0..1	CodeableConcept	Kind of assessment performed Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
description	Σ	0..1	string	Why/how the assessment was performed
subject	SΣ	1..1	Reference(US Core Patient Profile)	Patient or group assessed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional content defined by implementations
value		0..1	uri	Primitive value for uri
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
effective[x]	SΣ	0..1		Time of assessment
effectiveDateTime			dateTime
effectivePeriod			Period
date	Σ	0..1	dateTime	When the assessment was documented
assessor	Σ	0..1	Reference(Practitioner | PractitionerRole)	The clinician performing the assessment
previous		0..1	Reference(ClinicalImpression)	Reference to last assessment
problem	SΣ	1..*	Reference(Condition | AllergyIntolerance)	Relevant impressions of patient state
investigation		0..*	BackboneElement	One or more sets of investigations (signs, symptoms, etc.)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations.
item		0..*	Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)	Record of a specific investigation
protocol		0..*	uri	Clinical Protocol followed
summary		0..1	string	Summary of the assessment
finding		0..*	BackboneElement	Possible or likely findings and diagnoses
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemCodeableConcept		0..1	CodeableConcept	What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
itemReference		0..1	Reference(Condition | Observation | Media)	What was found
basis		0..1	string	Which investigations support finding
prognosisCodeableConcept		0..*	CodeableConcept	Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
prognosisReference		0..*	Reference(RiskAssessment)	RiskAssessment expressing likely outcome
supportingInfo		0..*	Reference(Resource)	Information supporting the clinical impression
note		0..*	Annotation	Comments made about the ClinicalImpression
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClinicalImpression.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClinicalImpression.status	required	ClinicalImpressionStatus
ClinicalImpression.statusReason	example
ClinicalImpression.code	example
ClinicalImpression.subject.type	extensible	ResourceType
ClinicalImpression.investigation.code	example	InvestigationType
ClinicalImpression.finding.itemCodeableConcept	example	Condition/Problem/DiagnosisCodes
ClinicalImpression.prognosisCodeableConcept	example	ClinicalImpressionPrognosis

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClinicalImpression

Summary

Mandatory: 1 element
Must-Support: 4 elements

Structures

This structure refers to these other structures:

• US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
• http://hl7.org/fhir/us/mcc/StructureDefinition/changePattern