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.
In scope of the eHealth Infrastructure, the ClinicalImpression resource is used for:
Except for the ClinicalImpression instance for the Practitioner assessment and for the ClinicalImpression instance for missing measurements, the one or more investigation.item refer to the Observation, QuestionnaireResponse, and Media instances submitted as a measurement.
The element code specifies what kind of the above uses is the case.
With the extension investigation.decisionRule, the ClinicalImpression is able to capture decision support invocations such as the automated triaging. This entails:
The ClinicalImpression instance for the Practitioner assessment refers to a ClinicalImpression instance of the other types. The reference is made with the element previous.
The element finding.itemCodeableConcept contains the Practitioner’s assessment of the measurement/triaging result/decision support result, that is whether the measurement/result is approved or approved also for registering in national document sharing infrastructure.
In case the Practitioner has comments or notes, these can be captured as one or more occurrences of the element note.text.
The official URL for this profile is:
http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression
This profile builds on ClinicalImpression.
This profile was published on Fri Jun 07 11:10:06 UTC 2019 as a draft by ehealth.sundhed.dk.
Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.
This structure is derived from ClinicalImpression
Summary
Mandatory: 2 elements
Must-Support: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
This structure is derived from ClinicalImpression
This structure is derived from ClinicalImpression
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalImpression | I | 0..* | A record of a clinical assessment performed to determine what problem(s) may affect the 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: Common Languages (extensible) | |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | Business identifier |
status | ?!Σ | 1..1 | code | draft | completed | entered-in-error Binding: ClinicalImpressionStatus (required) |
code | SΣ | 1..1 | CodeableConcept | Kind of assessment performed Binding: ClinicalImpressionCodes (required) |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
coding | Σ | 0..* | Coding | Code defined by a terminology system Binding: ClinicalImpressionCodes (required) |
text | Σ | 0..1 | string | Plain text representation of the concept |
description | Σ | 0..1 | string | Why/how the assessment was performed |
subject | Σ | 1..1 | Reference(eHealth Patient | Group) {r} | Patient or group assessed |
context | Σ | 1..1 | Reference(Encounter | eHealth EpisodeOfCare) {r} | Encounter or Episode created from |
effective[x] | Σ | 0..1 | dateTime, Period | Time of assessment |
date | Σ | 0..1 | dateTime | When the assessment was documented |
assessor | Σ | 0..1 | Reference(eHealth Practitioner) {r} | The clinician performing the assessment |
previous | 0..1 | Reference(eHealth ClinicalImpression) {r} | Reference to last assessment | |
problem | Σ | 0..* | Reference(eHealth Condition | AllergyIntolerance) {r} | Relevant impressions of patient state |
investigation | I | 0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
ehealth-clinicalimpression-decisionRule | 0..* | (Complex) | Decision rule. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionRule | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
extension | 0..* | Extension | Extension | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
url | 1..1 | uri | identifies the meaning of the extension | |
valueReference | 0..1 | Reference(Parameters) {cr} | Value of extension | |
url | 1..1 | uri | identifies the meaning of the extension | |
value[x] | 0..1 | base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, Meta | Value of extension | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
code | 1..1 | CodeableConcept | A name/code for the set Binding: Investigation Type (example) | |
item | 0..* | Reference(eHealth Observation | eHealth QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) {r} | Record of a specific investigation | |
protocol | 0..* | uri | Clinical Protocol followed | |
summary | 0..1 | string | Summary of the assessment | |
finding | I | 0..* | BackboneElement | Possible or likely findings and diagnoses |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
item[x] | 1..1 | CodeableConcept, Reference(eHealth Condition | eHealth Observation) {r} | What was found Binding: ClinicalImpressionFindingCodes (required) | |
basis | 0..1 | string | Which investigations support finding | |
prognosisCodeableConcept | 0..* | CodeableConcept | Estimate of likely outcome Binding: Clinical Impression Prognosis (example) | |
prognosisReference | 0..* | Reference(RiskAssessment) {r} | RiskAssessment expressing likely outcome | |
action | 0..* | Reference(ReferralRequest | eHealth ProcedureRequest | Procedure | MedicationRequest | eHealth Appointment) {r} | Action taken as part of assessment procedure | |
note | 0..* | Annotation | Comments made about the ClinicalImpression. | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
author[x] | Σ | 0..1 | Reference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson) {r}, string | Individual responsible for the annotation |
time | Σ | 0..1 | dateTime | When the annotation was made |
text | 1..1 | string | The annotation - text content | |
Documentation for this format |
This structure is derived from ClinicalImpression
Summary
Mandatory: 2 elements
Must-Support: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from ClinicalImpression
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalImpression | I | 0..* | A record of a clinical assessment performed to determine what problem(s) may affect the 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: Common Languages (extensible) | |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | Business identifier |
status | ?!Σ | 1..1 | code | draft | completed | entered-in-error Binding: ClinicalImpressionStatus (required) |
code | SΣ | 1..1 | CodeableConcept | Kind of assessment performed Binding: ClinicalImpressionCodes (required) |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
coding | Σ | 0..* | Coding | Code defined by a terminology system Binding: ClinicalImpressionCodes (required) |
text | Σ | 0..1 | string | Plain text representation of the concept |
description | Σ | 0..1 | string | Why/how the assessment was performed |
subject | Σ | 1..1 | Reference(eHealth Patient | Group) {r} | Patient or group assessed |
context | Σ | 1..1 | Reference(Encounter | eHealth EpisodeOfCare) {r} | Encounter or Episode created from |
effective[x] | Σ | 0..1 | dateTime, Period | Time of assessment |
date | Σ | 0..1 | dateTime | When the assessment was documented |
assessor | Σ | 0..1 | Reference(eHealth Practitioner) {r} | The clinician performing the assessment |
previous | 0..1 | Reference(eHealth ClinicalImpression) {r} | Reference to last assessment | |
problem | Σ | 0..* | Reference(eHealth Condition | AllergyIntolerance) {r} | Relevant impressions of patient state |
investigation | I | 0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
ehealth-clinicalimpression-decisionRule | 0..* | (Complex) | Decision rule. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionRule | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
extension | 0..* | Extension | Extension | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
url | 1..1 | uri | identifies the meaning of the extension | |
valueReference | 0..1 | Reference(Parameters) {cr} | Value of extension | |
url | 1..1 | uri | identifies the meaning of the extension | |
value[x] | 0..1 | base64Binary, boolean, code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, Meta | Value of extension | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
code | 1..1 | CodeableConcept | A name/code for the set Binding: Investigation Type (example) | |
item | 0..* | Reference(eHealth Observation | eHealth QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) {r} | Record of a specific investigation | |
protocol | 0..* | uri | Clinical Protocol followed | |
summary | 0..1 | string | Summary of the assessment | |
finding | I | 0..* | BackboneElement | Possible or likely findings and diagnoses |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
item[x] | 1..1 | CodeableConcept, Reference(eHealth Condition | eHealth Observation) {r} | What was found Binding: ClinicalImpressionFindingCodes (required) | |
basis | 0..1 | string | Which investigations support finding | |
prognosisCodeableConcept | 0..* | CodeableConcept | Estimate of likely outcome Binding: Clinical Impression Prognosis (example) | |
prognosisReference | 0..* | Reference(RiskAssessment) {r} | RiskAssessment expressing likely outcome | |
action | 0..* | Reference(ReferralRequest | eHealth ProcedureRequest | Procedure | MedicationRequest | eHealth Appointment) {r} | Action taken as part of assessment procedure | |
note | 0..* | Annotation | Comments made about the ClinicalImpression. | |
id | 0..1 | string | xml:id (or equivalent in JSON) | |
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
author[x] | Σ | 0..1 | Reference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson) {r}, string | Individual responsible for the annotation |
time | Σ | 0..1 | dateTime | When the annotation was made |
text | 1..1 | string | The annotation - text content | |
Documentation for this format |
Path | Name | Conformance | ValueSet |
ClinicalImpression.language | Common Languages | extensible | Common Languages |
ClinicalImpression.status | ClinicalImpressionStatus | required | ClinicalImpressionStatus |
ClinicalImpression.code | ClinicalImpressionCodes | required | ClinicalImpressionCodes |
ClinicalImpression.code.coding | ClinicalImpressionCodes | required | ClinicalImpressionCodes |
ClinicalImpression.investigation.code | Investigation Type | example | Investigation Type |
ClinicalImpression.finding.item[x] | ClinicalImpressionFindingCodes | required | ClinicalImpressionFindingCodes |
ClinicalImpression.prognosisCodeableConcept | Clinical Impression Prognosis | example | Clinical Impression Prognosis |
Id | Path | Details | Requirements |
dom-2 | ClinicalImpression | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-1 | ClinicalImpression | If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty() | |
dom-4 | 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-3 | ClinicalImpression | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource : contained.where(('#'+id in %resource.descendants().reference).not()).empty() | |
ele-1 | ClinicalImpression.investigation | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ele-1 | ClinicalImpression.finding | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) |