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

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.

Structure JSON Dependencies FHIRSchema Other Versions Dependant (0)Elements Summary

Name	Flags	Card	Type	Description & Constraints
ClinicalImpression		0..*		A clinical assessment performed when planning treatments and management strategies for a patient
identifier	Σ	0..*	Identifier	Business identifier
status *	?!Σ	1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown ClinicalImpressionStatus (required)
statusReason		0..1	CodeableConcept	Reason for current status ClinicalImpressionStatusReason (example)
description	Σ	0..1	string	Why/how the assessment was performed
subject *	Σ	1..1	Reference	Patient or group assessed
encounter	Σ	0..1	Reference	The Encounter during which this ClinicalImpression was created
effective[x]	Σ	0..1		Time of assessment
effectiveDateTime	Σ	0..1	dateTime
effectivePeriod	Σ	0..1	Period
date	Σ	0..1	dateTime	When the assessment was documented
performer	Σ	0..1	Reference	The clinician performing the assessment
previous		0..1	Reference	Reference to last assessment
problem	Σ	0..*	Reference	Relevant impressions of patient state
changePattern		0..1	CodeableConcept	Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change ClinicalImpressionChangePattern (example)
protocol		0..*	uri	Clinical Protocol followed
summary		0..1	string	Summary of the assessment
finding		0..*	BackboneElement	Possible or likely findings and diagnoses
item		0..1	CodeableReference	What was found ConditionKind (example)
basis		0..1	string	Which investigations support finding
prognosisCodeableConcept		0..*	CodeableConcept	Estimate of likely outcome ClinicalImpressionPrognosis (example)
prognosisReference		0..*	Reference	RiskAssessment expressing likely outcome
supportingInfo		0..*	Reference	Information supporting the clinical impression
note		0..*	Annotation	Comments made about the ClinicalImpression