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.
# | path | type | required | description |
---|---|---|---|---|
0 | resourceType |
string | * | Resource type identifier. Must be string "ClinicalImpression" |
1 | integer | * | Number of subrows | |
2 | id |
string | * | Logical id of this artifact |
3 | status |
code | in-progress | completed | entered-in-error | |
statusReason |
CodeableConcept | Reason for current status | ||
statusReason.coding |
Coding | Code defined by a terminology system | ||
4 | statusReason.coding.system |
uri | Identity of the terminology system | |
5 | statusReason.coding.version |
string | Version of the system - if relevant | |
6 | statusReason.coding.code |
code | Symbol in syntax defined by the system | |
7 | statusReason.coding.display |
string | Representation defined by the system | |
8 | statusReason.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
9 | statusReason.text |
string | Plain text representation of the concept | |
code |
CodeableConcept | Kind of assessment performed | ||
code.coding |
Coding | Code defined by a terminology system | ||
10 | code.coding.system |
uri | Identity of the terminology system | |
11 | code.coding.version |
string | Version of the system - if relevant | |
12 | code.coding.code |
code | Symbol in syntax defined by the system | |
13 | code.coding.display |
string | Representation defined by the system | |
14 | code.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
15 | code.text |
string | Plain text representation of the concept | |
16 | description |
string | Why/how the assessment was performed | |
subject |
Reference | Patient or group assessed | ||
17 | subject.reference |
string | Literal reference, Relative, internal or absolute URL | |
18 | subject.type |
uri | Type the reference refers to (e.g. "Patient") | |
subject.identifier |
Identifier | Logical reference, when literal reference is not known | ||
19 | subject.identifier.use |
code | usual | official | temp | secondary | old (If known) | |
subject.identifier.type |
CodeableConcept | Description of identifier | ||
subject.identifier.type.coding |
Coding | Code defined by a terminology system | ||
20 | subject.identifier.type.coding.system |
uri | Identity of the terminology system | |
21 | subject.identifier.type.coding.version |
string | Version of the system - if relevant | |
22 | subject.identifier.type.coding.code |
code | Symbol in syntax defined by the system | |
23 | subject.identifier.type.coding.display |
string | Representation defined by the system | |
24 | subject.identifier.type.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
25 | subject.identifier.type.text |
string | Plain text representation of the concept | |
26 | subject.identifier.system |
uri | The namespace for the identifier value | |
27 | subject.identifier.value |
string | The value that is unique | |
subject.identifier.period |
Period | Time period when id is/was valid for use | ||
28 | subject.identifier.period.start |
dateTime | Starting time with inclusive boundary | |
29 | subject.identifier.period.end |
dateTime | End time with inclusive boundary, if not ongoing | |
30 | subject.display |
string | Text alternative for the resource | |
encounter |
Reference | Encounter created as part of | ||
31 | encounter.reference |
string | Literal reference, Relative, internal or absolute URL | |
32 | encounter.type |
uri | Type the reference refers to (e.g. "Patient") | |
encounter.identifier |
Identifier | Logical reference, when literal reference is not known | ||
33 | encounter.identifier.use |
code | usual | official | temp | secondary | old (If known) | |
encounter.identifier.type |
CodeableConcept | Description of identifier | ||
encounter.identifier.type.coding |
Coding | Code defined by a terminology system | ||
34 | encounter.identifier.type.coding.system |
uri | Identity of the terminology system | |
35 | encounter.identifier.type.coding.version |
string | Version of the system - if relevant | |
36 | encounter.identifier.type.coding.code |
code | Symbol in syntax defined by the system | |
37 | encounter.identifier.type.coding.display |
string | Representation defined by the system | |
38 | encounter.identifier.type.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
39 | encounter.identifier.type.text |
string | Plain text representation of the concept | |
40 | encounter.identifier.system |
uri | The namespace for the identifier value | |
41 | encounter.identifier.value |
string | The value that is unique | |
encounter.identifier.period |
Period | Time period when id is/was valid for use | ||
42 | encounter.identifier.period.start |
dateTime | Starting time with inclusive boundary | |
43 | encounter.identifier.period.end |
dateTime | End time with inclusive boundary, if not ongoing | |
44 | encounter.display |
string | Text alternative for the resource | |
effective[x] |
Time of assessment | |||
45 | effectiveDateTime |
dateTime | ||
effectivePeriod |
Period | |||
46 | effectivePeriod.start |
dateTime | Starting time with inclusive boundary | |
47 | effectivePeriod.end |
dateTime | End time with inclusive boundary, if not ongoing | |
48 | date |
dateTime | When the assessment was documented | |
assessor |
Reference | The clinician performing the assessment | ||
49 | assessor.reference |
string | Literal reference, Relative, internal or absolute URL | |
50 | assessor.type |
uri | Type the reference refers to (e.g. "Patient") | |
assessor.identifier |
Identifier | Logical reference, when literal reference is not known | ||
51 | assessor.identifier.use |
code | usual | official | temp | secondary | old (If known) | |
assessor.identifier.type |
CodeableConcept | Description of identifier | ||
assessor.identifier.type.coding |
Coding | Code defined by a terminology system | ||
52 | assessor.identifier.type.coding.system |
uri | Identity of the terminology system | |
53 | assessor.identifier.type.coding.version |
string | Version of the system - if relevant | |
54 | assessor.identifier.type.coding.code |
code | Symbol in syntax defined by the system | |
55 | assessor.identifier.type.coding.display |
string | Representation defined by the system | |
56 | assessor.identifier.type.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
57 | assessor.identifier.type.text |
string | Plain text representation of the concept | |
58 | assessor.identifier.system |
uri | The namespace for the identifier value | |
59 | assessor.identifier.value |
string | The value that is unique | |
assessor.identifier.period |
Period | Time period when id is/was valid for use | ||
60 | assessor.identifier.period.start |
dateTime | Starting time with inclusive boundary | |
61 | assessor.identifier.period.end |
dateTime | End time with inclusive boundary, if not ongoing | |
62 | assessor.display |
string | Text alternative for the resource | |
previous |
Reference | Reference to last assessment | ||
63 | previous.reference |
string | Literal reference, Relative, internal or absolute URL | |
64 | previous.type |
uri | Type the reference refers to (e.g. "Patient") | |
previous.identifier |
Identifier | Logical reference, when literal reference is not known | ||
65 | previous.identifier.use |
code | usual | official | temp | secondary | old (If known) | |
previous.identifier.type |
CodeableConcept | Description of identifier | ||
previous.identifier.type.coding |
Coding | Code defined by a terminology system | ||
66 | previous.identifier.type.coding.system |
uri | Identity of the terminology system | |
67 | previous.identifier.type.coding.version |
string | Version of the system - if relevant | |
68 | previous.identifier.type.coding.code |
code | Symbol in syntax defined by the system | |
69 | previous.identifier.type.coding.display |
string | Representation defined by the system | |
70 | previous.identifier.type.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
71 | previous.identifier.type.text |
string | Plain text representation of the concept | |
72 | previous.identifier.system |
uri | The namespace for the identifier value | |
73 | previous.identifier.value |
string | The value that is unique | |
previous.identifier.period |
Period | Time period when id is/was valid for use | ||
74 | previous.identifier.period.start |
dateTime | Starting time with inclusive boundary | |
75 | previous.identifier.period.end |
dateTime | End time with inclusive boundary, if not ongoing | |
76 | previous.display |
string | Text alternative for the resource | |
77 | summary |
string | Summary of the assessment |
identifier
# | path | type | required | description |
---|---|---|---|---|
0 | string | * | Subrow identifier. Must be string "identifier" | |
identifier |
Identifier | Business identifier | ||
1 | identifier.use |
code | usual | official | temp | secondary | old (If known) | |
identifier.type |
CodeableConcept | Description of identifier | ||
identifier.type.coding |
Coding | Code defined by a terminology system | ||
2 | identifier.type.coding.system |
uri | Identity of the terminology system | |
3 | identifier.type.coding.version |
string | Version of the system - if relevant | |
4 | identifier.type.coding.code |
code | Symbol in syntax defined by the system | |
5 | identifier.type.coding.display |
string | Representation defined by the system | |
6 | identifier.type.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
7 | identifier.type.text |
string | Plain text representation of the concept | |
8 | identifier.system |
uri | The namespace for the identifier value | |
9 | identifier.value |
string | The value that is unique | |
identifier.period |
Period | Time period when id is/was valid for use | ||
10 | identifier.period.start |
dateTime | Starting time with inclusive boundary | |
11 | identifier.period.end |
dateTime | End time with inclusive boundary, if not ongoing |
problem
# | path | type | required | description |
---|---|---|---|---|
0 | string | * | Subrow identifier. Must be string "problem" | |
problem |
Reference | Relevant impressions of patient state | ||
1 | problem.reference |
string | Literal reference, Relative, internal or absolute URL | |
2 | problem.type |
uri | Type the reference refers to (e.g. "Patient") | |
problem.identifier |
Identifier | Logical reference, when literal reference is not known | ||
3 | problem.identifier.use |
code | usual | official | temp | secondary | old (If known) | |
problem.identifier.type |
CodeableConcept | Description of identifier | ||
problem.identifier.type.coding |
Coding | Code defined by a terminology system | ||
4 | problem.identifier.type.coding.system |
uri | Identity of the terminology system | |
5 | problem.identifier.type.coding.version |
string | Version of the system - if relevant | |
6 | problem.identifier.type.coding.code |
code | Symbol in syntax defined by the system | |
7 | problem.identifier.type.coding.display |
string | Representation defined by the system | |
8 | problem.identifier.type.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
9 | problem.identifier.type.text |
string | Plain text representation of the concept | |
10 | problem.identifier.system |
uri | The namespace for the identifier value | |
11 | problem.identifier.value |
string | The value that is unique | |
problem.identifier.period |
Period | Time period when id is/was valid for use | ||
12 | problem.identifier.period.start |
dateTime | Starting time with inclusive boundary | |
13 | problem.identifier.period.end |
dateTime | End time with inclusive boundary, if not ongoing | |
14 | problem.display |
string | Text alternative for the resource |
investigation
# | path | type | required | description |
---|---|---|---|---|
0 | string | * | Subrow identifier. Must be string "investigation" | |
investigation |
One or more sets of investigations (signs, symptoms, etc.) | |||
investigation.code |
CodeableConcept | A name/code for the set | ||
investigation.code.coding |
Coding | Code defined by a terminology system | ||
1 | investigation.code.coding.system |
uri | Identity of the terminology system | |
2 | investigation.code.coding.version |
string | Version of the system - if relevant | |
3 | investigation.code.coding.code |
code | Symbol in syntax defined by the system | |
4 | investigation.code.coding.display |
string | Representation defined by the system | |
5 | investigation.code.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
6 | investigation.code.text |
string | Plain text representation of the concept | |
investigation.item |
Reference | Record of a specific investigation | ||
7 | investigation.item.reference |
string | Literal reference, Relative, internal or absolute URL | |
8 | investigation.item.type |
uri | Type the reference refers to (e.g. "Patient") | |
investigation.item.identifier |
Identifier | Logical reference, when literal reference is not known | ||
9 | investigation.item.identifier.use |
code | usual | official | temp | secondary | old (If known) | |
investigation.item.identifier.type |
CodeableConcept | Description of identifier | ||
investigation.item.identifier.type.coding |
Coding | Code defined by a terminology system | ||
10 | investigation.item.identifier.type.coding.system |
uri | Identity of the terminology system | |
11 | investigation.item.identifier.type.coding.version |
string | Version of the system - if relevant | |
12 | investigation.item.identifier.type.coding.code |
code | Symbol in syntax defined by the system | |
13 | investigation.item.identifier.type.coding.display |
string | Representation defined by the system | |
14 | investigation.item.identifier.type.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
15 | investigation.item.identifier.type.text |
string | Plain text representation of the concept | |
16 | investigation.item.identifier.system |
uri | The namespace for the identifier value | |
17 | investigation.item.identifier.value |
string | The value that is unique | |
investigation.item.identifier.period |
Period | Time period when id is/was valid for use | ||
18 | investigation.item.identifier.period.start |
dateTime | Starting time with inclusive boundary | |
19 | investigation.item.identifier.period.end |
dateTime | End time with inclusive boundary, if not ongoing | |
20 | investigation.item.display |
string | Text alternative for the resource |
protocol
# | path | type | required | description |
---|---|---|---|---|
0 | string | * | Subrow identifier. Must be string "protocol" | |
1 | protocol |
uri | Clinical Protocol followed |
finding
# | path | type | required | description |
---|---|---|---|---|
0 | string | * | Subrow identifier. Must be string "finding" | |
finding |
Possible or likely findings and diagnoses | |||
finding.itemCodeableConcept |
CodeableConcept | What was found | ||
finding.itemCodeableConcept.coding |
Coding | Code defined by a terminology system | ||
1 | finding.itemCodeableConcept.coding.system |
uri | Identity of the terminology system | |
2 | finding.itemCodeableConcept.coding.version |
string | Version of the system - if relevant | |
3 | finding.itemCodeableConcept.coding.code |
code | Symbol in syntax defined by the system | |
4 | finding.itemCodeableConcept.coding.display |
string | Representation defined by the system | |
5 | finding.itemCodeableConcept.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
6 | finding.itemCodeableConcept.text |
string | Plain text representation of the concept | |
finding.itemReference |
Reference | What was found | ||
7 | finding.itemReference.reference |
string | Literal reference, Relative, internal or absolute URL | |
8 | finding.itemReference.type |
uri | Type the reference refers to (e.g. "Patient") | |
finding.itemReference.identifier |
Identifier | Logical reference, when literal reference is not known | ||
9 | finding.itemReference.identifier.use |
code | usual | official | temp | secondary | old (If known) | |
finding.itemReference.identifier.type |
CodeableConcept | Description of identifier | ||
finding.itemReference.identifier.type.coding |
Coding | Code defined by a terminology system | ||
10 | finding.itemReference.identifier.type.coding.system |
uri | Identity of the terminology system | |
11 | finding.itemReference.identifier.type.coding.version |
string | Version of the system - if relevant | |
12 | finding.itemReference.identifier.type.coding.code |
code | Symbol in syntax defined by the system | |
13 | finding.itemReference.identifier.type.coding.display |
string | Representation defined by the system | |
14 | finding.itemReference.identifier.type.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
15 | finding.itemReference.identifier.type.text |
string | Plain text representation of the concept | |
16 | finding.itemReference.identifier.system |
uri | The namespace for the identifier value | |
17 | finding.itemReference.identifier.value |
string | The value that is unique | |
finding.itemReference.identifier.period |
Period | Time period when id is/was valid for use | ||
18 | finding.itemReference.identifier.period.start |
dateTime | Starting time with inclusive boundary | |
19 | finding.itemReference.identifier.period.end |
dateTime | End time with inclusive boundary, if not ongoing | |
20 | finding.itemReference.display |
string | Text alternative for the resource | |
21 | finding.basis |
string | Which investigations support finding |
prognosisCodeableConcept
# | path | type | required | description |
---|---|---|---|---|
0 | string | * | Subrow identifier. Must be string "prognosisCodeableConcept" | |
prognosisCodeableConcept |
CodeableConcept | Estimate of likely outcome | ||
prognosisCodeableConcept.coding |
Coding | Code defined by a terminology system | ||
1 | prognosisCodeableConcept.coding.system |
uri | Identity of the terminology system | |
2 | prognosisCodeableConcept.coding.version |
string | Version of the system - if relevant | |
3 | prognosisCodeableConcept.coding.code |
code | Symbol in syntax defined by the system | |
4 | prognosisCodeableConcept.coding.display |
string | Representation defined by the system | |
5 | prognosisCodeableConcept.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
6 | prognosisCodeableConcept.text |
string | Plain text representation of the concept |
prognosisReference
# | path | type | required | description |
---|---|---|---|---|
0 | string | * | Subrow identifier. Must be string "prognosisReference" | |
prognosisReference |
Reference | RiskAssessment expressing likely outcome | ||
1 | prognosisReference.reference |
string | Literal reference, Relative, internal or absolute URL | |
2 | prognosisReference.type |
uri | Type the reference refers to (e.g. "Patient") | |
prognosisReference.identifier |
Identifier | Logical reference, when literal reference is not known | ||
3 | prognosisReference.identifier.use |
code | usual | official | temp | secondary | old (If known) | |
prognosisReference.identifier.type |
CodeableConcept | Description of identifier | ||
prognosisReference.identifier.type.coding |
Coding | Code defined by a terminology system | ||
4 | prognosisReference.identifier.type.coding.system |
uri | Identity of the terminology system | |
5 | prognosisReference.identifier.type.coding.version |
string | Version of the system - if relevant | |
6 | prognosisReference.identifier.type.coding.code |
code | Symbol in syntax defined by the system | |
7 | prognosisReference.identifier.type.coding.display |
string | Representation defined by the system | |
8 | prognosisReference.identifier.type.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
9 | prognosisReference.identifier.type.text |
string | Plain text representation of the concept | |
10 | prognosisReference.identifier.system |
uri | The namespace for the identifier value | |
11 | prognosisReference.identifier.value |
string | The value that is unique | |
prognosisReference.identifier.period |
Period | Time period when id is/was valid for use | ||
12 | prognosisReference.identifier.period.start |
dateTime | Starting time with inclusive boundary | |
13 | prognosisReference.identifier.period.end |
dateTime | End time with inclusive boundary, if not ongoing | |
14 | prognosisReference.display |
string | Text alternative for the resource |
supportingInfo
# | path | type | required | description |
---|---|---|---|---|
0 | string | * | Subrow identifier. Must be string "supportingInfo" | |
supportingInfo |
Reference | Information supporting the clinical impression | ||
1 | supportingInfo.reference |
string | Literal reference, Relative, internal or absolute URL | |
2 | supportingInfo.type |
uri | Type the reference refers to (e.g. "Patient") | |
supportingInfo.identifier |
Identifier | Logical reference, when literal reference is not known | ||
3 | supportingInfo.identifier.use |
code | usual | official | temp | secondary | old (If known) | |
supportingInfo.identifier.type |
CodeableConcept | Description of identifier | ||
supportingInfo.identifier.type.coding |
Coding | Code defined by a terminology system | ||
4 | supportingInfo.identifier.type.coding.system |
uri | Identity of the terminology system | |
5 | supportingInfo.identifier.type.coding.version |
string | Version of the system - if relevant | |
6 | supportingInfo.identifier.type.coding.code |
code | Symbol in syntax defined by the system | |
7 | supportingInfo.identifier.type.coding.display |
string | Representation defined by the system | |
8 | supportingInfo.identifier.type.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
9 | supportingInfo.identifier.type.text |
string | Plain text representation of the concept | |
10 | supportingInfo.identifier.system |
uri | The namespace for the identifier value | |
11 | supportingInfo.identifier.value |
string | The value that is unique | |
supportingInfo.identifier.period |
Period | Time period when id is/was valid for use | ||
12 | supportingInfo.identifier.period.start |
dateTime | Starting time with inclusive boundary | |
13 | supportingInfo.identifier.period.end |
dateTime | End time with inclusive boundary, if not ongoing | |
14 | supportingInfo.display |
string | Text alternative for the resource |
note
# | path | type | required | description |
---|---|---|---|---|
0 | string | * | Subrow identifier. Must be string "note" | |
note |
Annotation | Comments made about the ClinicalImpression | ||
note.author[x] |
Individual responsible for the annotation | |||
note.authorReference |
Reference | |||
1 | note.authorReference.reference |
string | Literal reference, Relative, internal or absolute URL | |
2 | note.authorReference.type |
uri | Type the reference refers to (e.g. "Patient") | |
note.authorReference.identifier |
Identifier | Logical reference, when literal reference is not known | ||
3 | note.authorReference.identifier.use |
code | usual | official | temp | secondary | old (If known) | |
note.authorReference.identifier.type |
CodeableConcept | Description of identifier | ||
note.authorReference.identifier.type.coding |
Coding | Code defined by a terminology system | ||
4 | note.authorReference.identifier.type.coding.system |
uri | Identity of the terminology system | |
5 | note.authorReference.identifier.type.coding.version |
string | Version of the system - if relevant | |
6 | note.authorReference.identifier.type.coding.code |
code | Symbol in syntax defined by the system | |
7 | note.authorReference.identifier.type.coding.display |
string | Representation defined by the system | |
8 | note.authorReference.identifier.type.coding.userSelected |
boolean | If this coding was chosen directly by the user | |
9 | note.authorReference.identifier.type.text |
string | Plain text representation of the concept | |
10 | note.authorReference.identifier.system |
uri | The namespace for the identifier value | |
11 | note.authorReference.identifier.value |
string | The value that is unique | |
note.authorReference.identifier.period |
Period | Time period when id is/was valid for use | ||
12 | note.authorReference.identifier.period.start |
dateTime | Starting time with inclusive boundary | |
13 | note.authorReference.identifier.period.end |
dateTime | End time with inclusive boundary, if not ongoing | |
14 | note.authorReference.display |
string | Text alternative for the resource | |
15 | note.authorString |
string | ||
16 | note.time |
dateTime | When the annotation was made | |
17 | note.text |
markdown | The annotation - text content (as markdown) |
ClinicalImpression,4,"example","completed",,,,,,,,,,,,,"This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident","Patient/example",,,,,,,,,,,,,,"Encounter/example",,,,,,,,,,,,,,,"2014-12-06T20:00:00+11:00","2014-12-06T22:33:00+11:00","2014-12-06T22:33:00+11:00","Practitioner/example",,,,,,,,,,,,,,,,,,,,,,,,,,,,"provisional diagnoses of laceration of head and traumatic brain injury (TBI)"
identifier,,,,,,,,,"12345",,
problem,,,,,,,,,,,,,,"MVA"
investigation,,,,,,"Initial Examination",,,,,,,,,,,,,,"deep laceration of the scalp (left temporo-occipital)"
finding,"http://hl7.org/fhir/sid/icd-9",,"850.0",,,,,,,,,,,,,,,,,,
{
"resourceType": "ClinicalImpression",
"id": "example",
"identifier": [
{
"value": "12345"
}
],
"status": "completed",
"description": "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident",
"subject": {
"reference": "Patient/example"
},
"encounter": {
"reference": "Encounter/example"
},
"effectivePeriod": {
"start": "2014-12-06T20:00:00+11:00",
"end": "2014-12-06T22:33:00+11:00"
},
"date": "2014-12-06T22:33:00+11:00",
"assessor": {
"reference": "Practitioner/example"
},
"problem": [
{
"display": "MVA"
}
],
"investigation": [
{
"code": {
"text": "Initial Examination"
},
"item": [
{
"display": "deep laceration of the scalp (left temporo-occipital)"
},
{
"display": "decreased level of consciousness"
},
{
"display": "disoriented to time and place"
},
{
"display": "restless"
}
]
}
],
"summary": "provisional diagnoses of laceration of head and traumatic brain injury (TBI)",
"finding": [
{
"itemCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-9",
"code": "850.0"
}
]
}
}
]
}