ClinicalImpression

ResourceClinical · SummaryTrial useMaturity 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.

StructureSearch parametersHL7 specificationStructureDefinition JSON

Tested supportFull test results →

Backends

PostgreSQLElasticsearch

Interactions

CreateReadUpdatePatchDelete

Search

13 of 13 parameters tested

Structure

Show inherited elements (14)

Element	Card.	Type	Description
identifierΣ	0..*	Identifier	Business identifier
statusRequired?!Σ	1..1	code	in-progress | completed | entered-in-errorBinding (required): clinicalimpression-status
statusReason	0..1	CodeableConcept	Reason for current status
codeΣ	0..1	CodeableConcept	Kind of assessment performed
descriptionΣ	0..1	string	Why/how the assessment was performed
subjectRequiredΣ	1..1	Reference(Patient | Group)	Patient or group assessed
encounterΣ	0..1	Reference(Encounter)	Encounter created as part of
effective[x]Σ	0..1	dateTime | Period	Time of assessment
dateΣ	0..1	dateTime	When the assessment was documented
assessorΣ	0..1	Reference(Practitioner | PractitionerRole)	The clinician performing the assessment
previous	0..1	Reference(ClinicalImpression)	Reference to last assessment
problemΣ	0..*	Reference(Condition | AllergyIntolerance)	Relevant impressions of patient state
investigation	0..*	BackboneElement	One or more sets of investigations (signs, symptoms, etc.)
codeRequired	1..1	CodeableConcept	A name/code for the setBinding (example): investigation-sets
item	0..*	Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)	Record of a specific investigation
protocol	0..*	uri	Clinical Protocol followed
summary	0..1	string	Summary of the assessment
finding	0..*	BackboneElement	Possible or likely findings and diagnoses
itemCodeableConcept	0..1	CodeableConcept	What was foundBinding (example): condition-code
itemReference	0..1	Reference(Condition | Observation | Media)	What was found
basis	0..1	string	Which investigations support finding
prognosisCodeableConcept	0..*	CodeableConcept	Estimate of likely outcomeBinding (example): clinicalimpression-prognosis
prognosisReference	0..*	Reference(RiskAssessment)	RiskAssessment expressing likely outcome
supportingInfo	0..*	Reference(Resource)	Information supporting the clinical impression
note	0..*	Annotation	Comments made about the ClinicalImpression

Σ in _summary results · ?! modifier element · 1.. required · inherited elements in grey

Search parameters

Query with GET [base]/ClinicalImpression?[parameter]=[value]. Type decides which modifiers and prefixes apply, see search features.

Parameter	Type	Description	PG	ES
assessor	reference	The clinician performing the assessment ClinicalImpression.assessor
date	date	When the assessment was documented ClinicalImpression.date
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
patient	reference	Patient or group assessed ClinicalImpression.subject.where(resolve() is Patient)
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

PG: PostgreSQL, ES: Elasticsearch. passes its TestScript checks, fails, not tested yet.

Common parameters on every resource (8)

_haste-health-author	reference	The author of the resource
_id	token	Logical id of this artifact
_lastUpdated	date	When the resource version last changed
_profile	uri	Profiles this resource claims to conform to
_security	token	Security Labels applied to this resource
_source	uri	Identifies where the resource comes from
_tag	token	Tags applied to this resource
_type	token	Derived from the R4B Definition