ClinicalImpression

Property	Value
Publisher
Name	ClinicalImpression
URL	http://hl7.org/fhir/StructureDefinition/ClinicalImpression
Status	draft
Description
Abstract	false

Structure

Path	Cardinality	Type	Description
ClinicalImpression	0..*	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.
ClinicalImpression.id	0..1	http://hl7.org/fhirpath/System.String	The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
ClinicalImpression.meta	0..1	Meta	The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
ClinicalImpression.implicitRules	0..1	uri	A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
ClinicalImpression.language	0..1	code	The base language in which the resource is written.
ClinicalImpression.text	0..1	Narrative	A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
ClinicalImpression.contained	0..*	Resource	These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
ClinicalImpression.extension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
ClinicalImpression.modifierExtension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
ClinicalImpression.identifier	0..*	Identifier	Business identifiers assigned to this clinical impression by the performer or other systems which remain constant as the resource is updated and propagates from server to server.
ClinicalImpression.status	1..1	code	Identifies the workflow status of the assessment.
ClinicalImpression.statusReason	0..1	CodeableConcept	Captures the reason for the current state of the ClinicalImpression.
ClinicalImpression.code	0..1	CodeableConcept	Categorizes the type of clinical assessment performed.
ClinicalImpression.description	0..1	string	A summary of the context and/or cause of the assessment - why / where it was performed, and what patient events/status prompted it.
ClinicalImpression.subject	1..1	Reference	The patient or group of individuals assessed as part of this record.
ClinicalImpression.encounter	0..1	Reference	The Encounter during which this ClinicalImpression was created or to which the creation of this record is tightly associated.
ClinicalImpression.effective[x]	0..1	dateTime	The point in time or period over which the subject was assessed.
ClinicalImpression.date	0..1	dateTime	Indicates when the documentation of the assessment was complete.
ClinicalImpression.assessor	0..1	Reference	The clinician performing the assessment.
ClinicalImpression.previous	0..1	Reference	A reference to the last assessment that was conducted on this patient. Assessments are often/usually ongoing in nature; a care provider (practitioner or team) will make new assessments on an ongoing basis as new data arises or the patient's conditions changes.
ClinicalImpression.problem	0..*	Reference	A list of the relevant problems/conditions for a patient.
ClinicalImpression.investigation	0..*	BackboneElement	One or more sets of investigations (signs, symptoms, etc.). The actual grouping of investigations varies greatly depending on the type and context of the assessment. These investigations may include data generated during the assessment process, or data previously generated and recorded that is pertinent to the outcomes.
ClinicalImpression.investigation.id	0..1	http://hl7.org/fhirpath/System.String	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
ClinicalImpression.investigation.extension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
ClinicalImpression.investigation.modifierExtension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
ClinicalImpression.investigation.code	1..1	CodeableConcept	A name/code for the group ("set") of investigations. Typically, this will be something like "signs", "symptoms", "clinical", "diagnostic", but the list is not constrained, and others such groups such as (exposure/family/travel/nutritional) history may be used.
ClinicalImpression.investigation.item	0..*	Reference	A record of a specific investigation that was undertaken.
ClinicalImpression.protocol	0..*	uri	Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.
ClinicalImpression.summary	0..1	string	A text summary of the investigations and the diagnosis.
ClinicalImpression.finding	0..*	BackboneElement	Specific findings or diagnoses that were considered likely or relevant to ongoing treatment.
ClinicalImpression.finding.id	0..1	http://hl7.org/fhirpath/System.String	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
ClinicalImpression.finding.extension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
ClinicalImpression.finding.modifierExtension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
ClinicalImpression.finding.itemCodeableConcept	0..1	CodeableConcept	Specific text or code for finding or diagnosis, which may include ruled-out or resolved conditions.
ClinicalImpression.finding.itemReference	0..1	Reference	Specific reference for finding or diagnosis, which may include ruled-out or resolved conditions.
ClinicalImpression.finding.basis	0..1	string	Which investigations support finding or diagnosis.
ClinicalImpression.prognosisCodeableConcept	0..*	CodeableConcept	Estimate of likely outcome.
ClinicalImpression.prognosisReference	0..*	Reference	RiskAssessment expressing likely outcome.
ClinicalImpression.supportingInfo	0..*	Reference	Information supporting the clinical impression.
ClinicalImpression.note	0..*	Annotation	Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear.

Search Parameters

Name	Type	Description	Expression
_text	string	Search on the narrative of the resource
_content	string	Search on the entire content of the resource
_id	token	Logical id of this artifact	Resource.id
_lastUpdated	date	When the resource version last changed	Resource.meta.lastUpdated
_profile	uri	Profiles this resource claims to conform to	Resource.meta.profile
_query	token	A custom search profile that describes a specific defined query operation
_security	token	Security Labels applied to this resource	Resource.meta.security
_source	uri	Identifies where the resource comes from	Resource.meta.source
_tag	token	Tags applied to this resource	Resource.meta.tag
date	date	Multiple Resources: * AllergyIntolerance: Date first version of the resource instance was recorded* CarePlan: Time period plan covers* CareTeam: Time period team covers* ClinicalImpression: When the assessment was documented* Composition: Composition editing time* Consent: When this Consent was created or indexed* DiagnosticReport: The clinically relevant time of the report* Encounter: A date within the period the Encounter lasted* EpisodeOfCare: The provided date search value falls within the episode of care's period* FamilyMemberHistory: When history was recorded or last updated* Flag: Time period when flag is active* Immunization: Vaccination (non)-Administration Date* List: When the list was prepared* Observation: Obtained date/time. If the obtained element is a period, a date that falls in the period* Procedure: When the procedure was performed* RiskAssessment: When was assessment made?* SupplyRequest: When the request was made	AllergyIntolerance.recordedDate / CarePlan.period / CareTeam.period / ClinicalImpression.date / Composition.date / Consent.dateTime / DiagnosticReport.effective / Encounter.period / EpisodeOfCare.period / FamilyMemberHistory.date / Flag.period / Immunization.occurrence / List.date / Observation.effective / Procedure.performed / (RiskAssessment.occurrence.ofType(dateTime)) / SupplyRequest.authoredOn
patient	reference	Multiple Resources: * AllergyIntolerance: Who the sensitivity is for* CarePlan: Who the care plan is for* CareTeam: Who care team is for* ClinicalImpression: Patient or group assessed* Composition: Who and/or what the composition is about* Condition: Who has the condition?* Consent: Who the consent applies to* DetectedIssue: Associated patient* DeviceRequest: Individual the service is ordered for* DeviceUseStatement: Search by subject - a patient* DiagnosticReport: The subject of the report if a patient* DocumentManifest: The subject of the set of documents* DocumentReference: Who/what is the subject of the document* Encounter: The patient or group present at the encounter* EpisodeOfCare: The patient who is the focus of this episode of care* FamilyMemberHistory: The identity of a subject to list family member history items for* Flag: The identity of a subject to list flags for* Goal: Who this goal is intended for* ImagingStudy: Who the study is about* Immunization: The patient for the vaccination record* List: If all resources have the same subject* MedicationAdministration: The identity of a patient to list administrations for* MedicationDispense: The identity of a patient to list dispenses for* MedicationRequest: Returns prescriptions for a specific patient* MedicationStatement: Returns statements for a specific patient.* NutritionOrder: The identity of the person who requires the diet, formula or nutritional supplement* Observation: The subject that the observation is about (if patient)* Procedure: Search by subject - a patient* RiskAssessment: Who/what does assessment apply to?* ServiceRequest: Search by subject - a patient* SupplyDelivery: Patient for whom the item is supplied* VisionPrescription: The identity of a patient to list dispenses for	AllergyIntolerance.patient / CarePlan.subject.where(resolve() is Patient) / CareTeam.subject.where(resolve() is Patient) / ClinicalImpression.subject.where(resolve() is Patient) / Composition.subject.where(resolve() is Patient) / Condition.subject.where(resolve() is Patient) / Consent.patient / DetectedIssue.patient / DeviceRequest.subject.where(resolve() is Patient) / DeviceUseStatement.subject / DiagnosticReport.subject.where(resolve() is Patient) / DocumentManifest.subject.where(resolve() is Patient) / DocumentReference.subject.where(resolve() is Patient) / Encounter.subject.where(resolve() is Patient) / EpisodeOfCare.patient / FamilyMemberHistory.patient / Flag.subject.where(resolve() is Patient) / Goal.subject.where(resolve() is Patient) / ImagingStudy.subject.where(resolve() is Patient) / Immunization.patient / List.subject.where(resolve() is Patient) / MedicationAdministration.subject.where(resolve() is Patient) / MedicationDispense.subject.where(resolve() is Patient) / MedicationRequest.subject.where(resolve() is Patient) / MedicationStatement.subject.where(resolve() is Patient) / NutritionOrder.patient / Observation.subject.where(resolve() is Patient) / Procedure.subject.where(resolve() is Patient) / RiskAssessment.subject.where(resolve() is Patient) / ServiceRequest.subject.where(resolve() is Patient) / SupplyDelivery.patient / VisionPrescription.patient
assessor	reference	The clinician performing the assessment	ClinicalImpression.assessor
encounter	reference	Encounter created as part of	ClinicalImpression.encounter
finding-code	token	What was found	ClinicalImpression.finding.itemCodeableConcept
finding-ref	reference	What was found	ClinicalImpression.finding.itemReference
identifier	token	Business identifier	ClinicalImpression.identifier
investigation	reference	Record of a specific investigation	ClinicalImpression.investigation.item
previous	reference	Reference to last assessment	ClinicalImpression.previous
problem	reference	Relevant impressions of patient state	ClinicalImpression.problem
status	token	in-progress / completed / entered-in-error	ClinicalImpression.status
subject	reference	Patient or group assessed	ClinicalImpression.subject
supporting-info	reference	Information supporting the clinical impression	ClinicalImpression.supportingInfo
_iguhealth-version-seq	number	The version sequence of the resource	Resource.meta.extension.where(url='https://iguhealth.app/version-sequence').value
_iguhealth-author	reference	The author of the resource	Resource.meta.extension.where(url='https://iguhealth.app/author').value