http://hl7.org/fhir/StructureDefinition/ClinicalImpression|4.0.1
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.
| Name | Flags | Card | Type | Description & Constraints |
|---|---|---|---|---|
ClinicalImpression | 0..* | A clinical assessment performed when planning treatments and management strategies for a patient | ||
Σ | 0..* | Identifier | Business identifier | |
?!Σ | 1..1 | code | in-progress | completed | entered-in-error ClinicalImpressionStatus (required) | |
| 0..1 | CodeableConcept | Reason for current status ClinicalImpressionStatusReason (example) | ||
Σ | 0..1 | CodeableConcept | Kind of assessment performed ClinicalImpressionCode (example) | |
Σ | 0..1 | string | Why/how the assessment was performed | |
Σ | 1..1 | Reference | Patient or group assessed | |
Σ | 0..1 | Reference | Encounter created as part of | |
Σ | 0..1 | Time of assessment | ||
Σ | 0..1 | dateTime | ||
Σ | 0..1 | Period | ||
Σ | 0..1 | dateTime | When the assessment was documented | |
Σ | 0..1 | Reference | The clinician performing the assessment | |
| 0..1 | Reference | Reference to last assessment | ||
Σ | 0..* | Reference | Relevant impressions of patient state | |
| 0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) | ||
| 1..1 | CodeableConcept | A name/code for the set InvestigationGroupType (example) | ||
| 0..* | Reference | Record of a specific investigation | ||
| 0..* | uri | Clinical Protocol followed | ||
| 0..1 | string | Summary of the assessment | ||
| 0..* | BackboneElement | Possible or likely findings and diagnoses | ||
| 0..1 | CodeableConcept | What was found ConditionKind (example) | ||
| 0..1 | Reference | What was found | ||
| 0..1 | string | Which investigations support finding | ||
| 0..* | CodeableConcept | Estimate of likely outcome ClinicalImpressionPrognosis (example) | ||
| 0..* | Reference | RiskAssessment expressing likely outcome | ||
| 0..* | Reference | Information supporting the clinical impression | ||
| 0..* | Annotation | Comments made about the ClinicalImpression |