http://hl7.org/fhir/StructureDefinition/ClinicalImpression|5.0.0

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: {isModifier: false, short: Why/how the assessment was performed, mustSupport: false, isSummary: true, index: 3}
  date: {isModifier: false, short: When the assessment was documented, mustSupport: false, isSummary: true, index: 8}
  protocol: {isModifier: false, short: Clinical Protocol followed, mustSupport: false, array: true, isSummary: false, index: 13}
  supportingInfo: {isModifier: false, short: Information supporting the clinical impression, mustSupport: false, array: true, isSummary: false, index: 20}
  encounter: {isModifier: false, short: The Encounter during which this ClinicalImpression was created, mustSupport: false, isSummary: true, index: 5}
  changePattern:
    isModifier: false
    short: Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/clinicalimpression-change-pattern'}
    isSummary: false
    index: 12
  problem: {isModifier: false, short: Relevant impressions of patient state, mustSupport: false, array: true, isSummary: true, index: 11}
  statusReason:
    isModifier: false
    short: Reason for current status
    mustSupport: false
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/clinicalimpression-status-reason'}
    isSummary: false
    index: 2
  note: {isModifier: false, short: Comments made about the ClinicalImpression, mustSupport: false, array: true, isSummary: false, index: 21}
  summary: {isModifier: false, short: Summary of the assessment, mustSupport: false, isSummary: false, index: 14}
  prognosisCodeableConcept:
    isModifier: false
    short: Estimate of likely outcome
    mustSupport: false
    array: true
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis'}
    isSummary: false
    index: 18
  status:
    isModifier: true
    short: preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/event-status|5.0.0'}
    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:
    isModifier: false
    short: Time of assessment
    mustSupport: false
    choices: []
    isSummary: true
    index: 7
  previous: {isModifier: false, short: Reference to last assessment, mustSupport: false, isSummary: false, index: 10}
  identifier: {isModifier: false, short: Business identifier, mustSupport: false, array: true, isSummary: true, index: 0}
  finding:
    isModifier: false
    short: Possible or likely findings and diagnoses
    mustSupport: false
    array: true
    isSummary: false
    index: 15
    elements:
      item:
        isModifier: false
        short: What was found
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/condition-code'}
        isSummary: false
        index: 16
      basis: {isModifier: false, short: Which investigations support finding, mustSupport: false, isSummary: false, index: 17}
  prognosisReference: {isModifier: false, short: RiskAssessment expressing likely outcome, mustSupport: false, array: true, isSummary: false, index: 19}
  subject: {isModifier: false, short: Patient or group assessed, mustSupport: false, isSummary: true, index: 4}
  performer: {isModifier: false, short: The clinician performing the assessment, mustSupport: false, isSummary: true, index: 9}
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ClinicalImpression
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 5.0.0
required: [status, subject]