http://hl7.org/fhir/StructureDefinition/ClinicalImpression|4.0.1

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.
derivation: specialization
name: ClinicalImpression
type: ClinicalImpression
elements:
  description: {short: Why/how the assessment was performed, isSummary: true, index: 4}
  date: {short: When the assessment was documented, isSummary: true, index: 9}
  investigation:
    short: One or more sets of investigations (signs, symptoms, etc.)
    array: true
    index: 13
    elements:
      code:
        short: A name/code for the set
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/investigation-sets'}
        index: 14
      item: {short: Record of a specific investigation, array: true, index: 15}
    required: [code]
  protocol: {short: Clinical Protocol followed, array: true, index: 16}
  assessor: {short: The clinician performing the assessment, isSummary: true, index: 10}
  supportingInfo: {short: Information supporting the clinical impression, array: true, index: 24}
  encounter: {short: Encounter created as part of, isSummary: true, index: 6}
  problem: {short: Relevant impressions of patient state, array: true, isSummary: true, index: 12}
  statusReason: {short: Reason for current status, index: 2}
  note: {short: Comments made about the ClinicalImpression, array: true, index: 25}
  summary: {short: Summary of the assessment, index: 17}
  prognosisCodeableConcept:
    short: Estimate of likely outcome
    array: true
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis'}
    index: 22
  status:
    isModifier: true
    short: in-progress | completed | entered-in-error
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1'}
    isModifierReason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    isSummary: true
    index: 1
  effective:
    short: Time of assessment
    choices: []
    isSummary: true
    index: 8
  previous: {short: Reference to last assessment, index: 11}
  code: {short: Kind of assessment performed, isSummary: true, index: 3}
  identifier: {short: Business identifier, array: true, isSummary: true, index: 0}
  finding:
    short: Possible or likely findings and diagnoses
    array: true
    index: 18
    elements:
      itemCodeableConcept:
        short: What was found
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/condition-code'}
        index: 19
      itemReference: {short: What was found, index: 20}
      basis: {short: Which investigations support finding, index: 21}
  prognosisReference: {short: RiskAssessment expressing likely outcome, array: true, index: 23}
  subject: {short: Patient or group assessed, isSummary: true, index: 5}
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ClinicalImpression
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 4.0.1
required: [status, subject]