2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Clinicalassessment.questionnaire

This is an example form generated from the questionnaire. See also the XML or JSON format.

Clinicalassessment.questionnaire - FHIR v0.4.0 Form
2nd DSTU Draft For Comment

This is an example form generated from the questionnaire. See also the XML or JSON format

A clinical assessment performed when planning treatments and management strategies for a patient

ClinicalAssessment
ClinicalAssessment.id
ClinicalAssessment.id.value Logical id of this artefact
ClinicalAssessment.id 1

Metadata about the resource

ClinicalAssessment.meta
ClinicalAssessment.meta 1
ClinicalAssessment.implicitRules
ClinicalAssessment.implicitRules.value A set of rules under which this content was created
ClinicalAssessment.implicitRules 1
ClinicalAssessment.language
ClinicalAssessment.language.value language
ClinicalAssessment.language 1

Text summary of the resource, for human interpretation

ClinicalAssessment.text
ClinicalAssessment.text 1

Contained, inline Resources

ClinicalAssessment.contained
ClinicalAssessment.contained 1
ClinicalAssessment.patient
ClinicalAssessment.patient.value The patient being asssesed
ClinicalAssessment.patient 1
ClinicalAssessment.assessor
ClinicalAssessment.assessor.value The clinicial performing the assessment
ClinicalAssessment.assessor 1
ClinicalAssessment.date
ClinicalAssessment.date.value When the assessment occurred
ClinicalAssessment.date 1
ClinicalAssessment.description
ClinicalAssessment.description.value Why/how the assessment was performed
ClinicalAssessment.description 1
ClinicalAssessment.previous
ClinicalAssessment.previous.value Reference to last assessment
ClinicalAssessment.previous 1

General assessment of patient state

ClinicalAssessment.problem
ClinicalAssessment.problem._type type
ClinicalAssessment.problem._Condition
ClinicalAssessment.problem._Condition.value Condition
ClinicalAssessment.problem._Condition 1
ClinicalAssessment.problem._AllergyIntolerance
ClinicalAssessment.problem._AllergyIntolerance.value AllergyIntolerance
ClinicalAssessment.problem._AllergyIntolerance 1
ClinicalAssessment.problem 1
ClinicalAssessment.careplan
ClinicalAssessment.careplan.value A specific careplan that prompted this assessment
ClinicalAssessment.careplan 1
ClinicalAssessment.referral
ClinicalAssessment.referral.value A specific referral that lead to this assessment
ClinicalAssessment.referral 1

One or more sets of investigations (signs, symptions, etc)

ClinicalAssessment.investigations
ClinicalAssessment.investigations.id
ClinicalAssessment.investigations.id.value xml:id (or equivalent in JSON)
ClinicalAssessment.investigations.id 1

A name/code for the set

ClinicalAssessment.investigations.code
ClinicalAssessment.investigations.code.coding code:
ClinicalAssessment.investigations.code.text text:
ClinicalAssessment.investigations.code 1

Record of a specific investigation

ClinicalAssessment.investigations.item
ClinicalAssessment.investigations.item._type type
ClinicalAssessment.investigations.item._Observation
ClinicalAssessment.investigations.item._Observation.value Observation
ClinicalAssessment.investigations.item._Observation 1
ClinicalAssessment.investigations.item._QuestionnaireAnswers
ClinicalAssessment.investigations.item._QuestionnaireAnswers.value QuestionnaireAnswers
ClinicalAssessment.investigations.item._QuestionnaireAnswers 1
ClinicalAssessment.investigations.item._FamilyHistory
ClinicalAssessment.investigations.item._FamilyHistory.value FamilyHistory
ClinicalAssessment.investigations.item._FamilyHistory 1
ClinicalAssessment.investigations.item._DiagnosticReport
ClinicalAssessment.investigations.item._DiagnosticReport.value DiagnosticReport
ClinicalAssessment.investigations.item._DiagnosticReport 1
ClinicalAssessment.investigations.item 1
ClinicalAssessment.investigations 1
ClinicalAssessment.protocol
ClinicalAssessment.protocol.value Clinical Protocol followed
ClinicalAssessment.protocol 1
ClinicalAssessment.summary
ClinicalAssessment.summary.value Summary of the assessment
ClinicalAssessment.summary 1

Possible or likely diagnosis

ClinicalAssessment.diagnosis
ClinicalAssessment.diagnosis.id
ClinicalAssessment.diagnosis.id.value xml:id (or equivalent in JSON)
ClinicalAssessment.diagnosis.id 1

Specific text or code for diagnosis

ClinicalAssessment.diagnosis.item
ClinicalAssessment.diagnosis.item.coding code:
ClinicalAssessment.diagnosis.item.text text:
ClinicalAssessment.diagnosis.item 1
ClinicalAssessment.diagnosis.cause
ClinicalAssessment.diagnosis.cause.value Which investigations support diagnosis
ClinicalAssessment.diagnosis.cause 1
ClinicalAssessment.diagnosis 1

Diagnosies/conditions resolved since previous assessment

ClinicalAssessment.resolved
ClinicalAssessment.resolved.coding code:
ClinicalAssessment.resolved.text text:
ClinicalAssessment.resolved 1

Diagnosis considered not possible

ClinicalAssessment.ruledOut
ClinicalAssessment.ruledOut.id
ClinicalAssessment.ruledOut.id.value xml:id (or equivalent in JSON)
ClinicalAssessment.ruledOut.id 1

Specific text of code for diagnosis

ClinicalAssessment.ruledOut.item
ClinicalAssessment.ruledOut.item.coding code:
ClinicalAssessment.ruledOut.item.text text:
ClinicalAssessment.ruledOut.item 1
ClinicalAssessment.ruledOut.reason
ClinicalAssessment.ruledOut.reason.value Grounds for elimination
ClinicalAssessment.ruledOut.reason 1
ClinicalAssessment.ruledOut 1
ClinicalAssessment.prognosis
ClinicalAssessment.prognosis.value Estimate of likely outcome
ClinicalAssessment.prognosis 1
ClinicalAssessment.plan
ClinicalAssessment.plan.value Plan of action after assessment
ClinicalAssessment.plan 1

Actions taken during assessment

ClinicalAssessment.action
ClinicalAssessment.action._type type
ClinicalAssessment.action._ReferralRequest
ClinicalAssessment.action._ReferralRequest.value ReferralRequest
ClinicalAssessment.action._ReferralRequest 1
ClinicalAssessment.action._ProcedureRequest
ClinicalAssessment.action._ProcedureRequest.value ProcedureRequest
ClinicalAssessment.action._ProcedureRequest 1
ClinicalAssessment.action._Procedure
ClinicalAssessment.action._Procedure.value Procedure
ClinicalAssessment.action._Procedure 1
ClinicalAssessment.action._MedicationPrescription
ClinicalAssessment.action._MedicationPrescription.value MedicationPrescription
ClinicalAssessment.action._MedicationPrescription 1
ClinicalAssessment.action._DiagnosticOrder
ClinicalAssessment.action._DiagnosticOrder.value DiagnosticOrder
ClinicalAssessment.action._DiagnosticOrder 1
ClinicalAssessment.action._NutritionOrder
ClinicalAssessment.action._NutritionOrder.value NutritionOrder
ClinicalAssessment.action._NutritionOrder 1
ClinicalAssessment.action._Supply
ClinicalAssessment.action._Supply.value Supply
ClinicalAssessment.action._Supply 1
ClinicalAssessment.action._Appointment
ClinicalAssessment.action._Appointment.value Appointment
ClinicalAssessment.action._Appointment 1
ClinicalAssessment.action 1
ClinicalAssessment 1