Skip to main content

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.

Properties

NameCardTypeDescription
id0..1stringLogical id of this artifact
meta0..1MetaMetadata about the resource
implicitRules0..1uriA set of rules under which this content was created
language0..1codeLanguage of the resource content
text0..1NarrativeText summary of the resource, for human interpretation
contained0..*ResourceContained, inline Resources
extension0..*ExtensionAdditional content defined by implementations
modifierExtension0..*ExtensionExtensions that cannot be ignored
identifier0..*IdentifierBusiness identifier
status1..1codein-progress | completed | entered-in-error
statusReason0..1CodeableConceptReason for current status
code0..1CodeableConceptKind of assessment performed
description0..1stringWhy/how the assessment was performed
subject1..1ReferencePatient or group assessed
encounter0..1ReferenceEncounter created as part of
effective[x]0..1dateTimeTime of assessment
date0..1dateTimeWhen the assessment was documented
assessor0..1ReferenceThe clinician performing the assessment
previous0..1ReferenceReference to last assessment
problem0..*ReferenceRelevant impressions of patient state
investigation0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
protocol0..*uriClinical Protocol followed
summary0..1stringSummary of the assessment
finding0..*BackboneElementPossible or likely findings and diagnoses
prognosisCodeableConcept0..*CodeableConceptEstimate of likely outcome
prognosisReference0..*ReferenceRiskAssessment expressing likely outcome
supportingInfo0..*ReferenceInformation supporting the clinical impression
note0..*AnnotationComments made about the ClinicalImpression

Search Parameters

NameTypeDescriptionExpression
datedateWhen the assessment was documentedClinicalImpression.date
patientreferencePatient or group assessedClinicalImpression.subject
assessorreferenceThe clinician performing the assessmentClinicalImpression.assessor
encounterreferenceEncounter created as part ofClinicalImpression.encounter
finding-codetokenWhat was foundClinicalImpression.finding.itemCodeableConcept
finding-refreferenceWhat was foundClinicalImpression.finding.itemReference
identifiertokenBusiness identifierClinicalImpression.identifier
investigationreferenceRecord of a specific investigationClinicalImpression.investigation.item
previousreferenceReference to last assessmentClinicalImpression.previous
problemreferenceRelevant impressions of patient stateClinicalImpression.problem
statustokenin-progress | completed | entered-in-errorClinicalImpression.status
subjectreferencePatient or group assessedClinicalImpression.subject
supporting-inforeferenceInformation supporting the clinical impressionClinicalImpression.supportingInfo