ClinicalImpression

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.

Columns

Header row
# 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
Row 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
Row 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
Row 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
Row protocol
# path type required description
0 string * Subrow identifier. Must be string "protocol"
1 protocol uri Clinical Protocol followed
Row 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
Row 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
Row 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
Row 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
Row 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)

Examples

Example #1
Input CSV
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",,,,,,,,,,,,,,,,,,
Resulting resource
{
  "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"
          }
        ]
      }
    }
  ]
}