Profile: ehealth-clinicalimpression

StructureDefinition: ehealth-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.

Scope and Usage

In scope of the eHealth Infrastructure, the ClinicalImpression resource is used for:

representing the result of automated triaging based on comparing of submitted measurements to references ranges defined in the CarePlan/ProcedureRequest.
capturing assessment made by a Practitioner of a ClinicalImpression for triaging result

Decision Support / Triaging Result

With the extension investigation.decisionRule, the ClinicalImpression is able to capture decision support invocations such as the automated triaging. This entails:

decision rule identification
decision rule input and output parameter definitions
actual parameter values used at invocation
actual output parameter values resulting from the decision rule execution
possible errors in executing a decision rule are captured in one or more OperationOutcome.

Formal Views of Profile Content

The official URL for this profile is:

http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression

This profile builds on ClinicalImpression.

This profile was published on Wed Mar 06 14:43:56 UTC 2019 as a draft by ehealth.sundhed.dk.

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

This structure is derived from ClinicalImpression

Summary

Mandatory: 2 elements
Must-Support: 1 element

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionRule

This structure is derived from ClinicalImpression

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*		A record of a clinical assessment performed to determine what problem(s) may affect the patient.
code	S	1..1	CodeableConcept
subject		1..1	Reference(eHealth Patient \| Group)
context		1..1	Reference(Encounter \| eHealth EpisodeOfCare)
assessor		0..1	Reference(eHealth Practitioner)
previous		0..1	Reference(eHealth ClinicalImpression)
investigation		0..*	BackboneElement	One or more sets of investigations (signs, symptions, etc.)
ehealth-clinicalimpression-decisionRule		0..*	(Complex)	Decision rule. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionRule
item		0..*	Reference(eHealth Observation \| eHealth QuestionnaireResponse \| FamilyMemberHistory \| DiagnosticReport \| RiskAssessment \| ImagingStudy)
finding		0..*	BackboneElement
item[x]		1..1	CodeableConcept, Reference(eHealth Condition \| eHealth Observation)	Binding: ClinicalImpressionFindingCodes (required)
action		0..*	Reference(ReferralRequest \| eHealth ProcedureRequest \| Procedure \| MedicationRequest \| Appointment)
note		0..*	Annotation	Comments made about the ClinicalImpression.
author[x]		0..1	Reference(eHealth Practitioner \| eHealth Patient \| eHealth RelatedPerson), string
Documentation for this format

This structure is derived from ClinicalImpression

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression	I	0..*		A record of a clinical assessment performed to determine what problem(s) may affect the patient.
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: Common Languages (extensible)
text	I	0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business identifier
status	?!Σ	1..1	code	draft \| completed \| entered-in-error Binding: ClinicalImpressionStatus (required)
code	SΣ	1..1	CodeableConcept	Kind of assessment performed Binding: (unbound) (example)
description	Σ	0..1	string	Why/how the assessment was performed
subject	Σ	1..1	Reference(eHealth Patient \| Group)	Patient or group assessed
context	Σ	1..1	Reference(Encounter \| eHealth EpisodeOfCare)	Encounter or Episode created from
effective[x]	Σ	0..1	dateTime, Period	Time of assessment
date	Σ	0..1	dateTime	When the assessment was documented
assessor	Σ	0..1	Reference(eHealth Practitioner)	The clinician performing the assessment
previous		0..1	Reference(eHealth ClinicalImpression)	Reference to last assessment
problem	Σ	0..*	Reference(Condition \| AllergyIntolerance)	Relevant impressions of patient state
investigation	I	0..*	BackboneElement	One or more sets of investigations (signs, symptions, etc.)
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
ehealth-clinicalimpression-decisionRule		0..*	(Complex)	Decision rule. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionRule
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
code		1..1	CodeableConcept	A name/code for the set Binding: Investigation Type (example)
item		0..*	Reference(eHealth Observation \| eHealth QuestionnaireResponse \| FamilyMemberHistory \| DiagnosticReport \| RiskAssessment \| ImagingStudy)	Record of a specific investigation
protocol		0..*	uri	Clinical Protocol followed
summary		0..1	string	Summary of the assessment
finding	I	0..*	BackboneElement	Possible or likely findings and diagnoses
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
item[x]		1..1	CodeableConcept, Reference(eHealth Condition \| eHealth Observation)	What was found Binding: ClinicalImpressionFindingCodes (required)
basis		0..1	string	Which investigations support finding
prognosisCodeableConcept		0..*	CodeableConcept	Estimate of likely outcome Binding: Clinical Impression Prognosis (example)
prognosisReference		0..*	Reference(RiskAssessment)	RiskAssessment expressing likely outcome
action		0..*	Reference(ReferralRequest \| eHealth ProcedureRequest \| Procedure \| MedicationRequest \| Appointment)	Action taken as part of assessment procedure
note		0..*	Annotation	Comments made about the ClinicalImpression.
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1	Reference(eHealth Practitioner \| eHealth Patient \| eHealth RelatedPerson), string	Individual responsible for the annotation
time	Σ	0..1	dateTime	When the annotation was made
text		1..1	string	The annotation - text content
Documentation for this format

This structure is derived from ClinicalImpression

Summary

Mandatory: 2 elements
Must-Support: 1 element

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionRule

Differential View

This structure is derived from ClinicalImpression

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*		A record of a clinical assessment performed to determine what problem(s) may affect the patient.
code	S	1..1	CodeableConcept
subject		1..1	Reference(eHealth Patient \| Group)
context		1..1	Reference(Encounter \| eHealth EpisodeOfCare)
assessor		0..1	Reference(eHealth Practitioner)
previous		0..1	Reference(eHealth ClinicalImpression)
investigation		0..*	BackboneElement	One or more sets of investigations (signs, symptions, etc.)
ehealth-clinicalimpression-decisionRule		0..*	(Complex)	Decision rule. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionRule
item		0..*	Reference(eHealth Observation \| eHealth QuestionnaireResponse \| FamilyMemberHistory \| DiagnosticReport \| RiskAssessment \| ImagingStudy)
finding		0..*	BackboneElement
item[x]		1..1	CodeableConcept, Reference(eHealth Condition \| eHealth Observation)	Binding: ClinicalImpressionFindingCodes (required)
action		0..*	Reference(ReferralRequest \| eHealth ProcedureRequest \| Procedure \| MedicationRequest \| Appointment)
note		0..*	Annotation	Comments made about the ClinicalImpression.
author[x]		0..1	Reference(eHealth Practitioner \| eHealth Patient \| eHealth RelatedPerson), string
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression	I	0..*		A record of a clinical assessment performed to determine what problem(s) may affect the patient.
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: Common Languages (extensible)
text	I	0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business identifier
status	?!Σ	1..1	code	draft \| completed \| entered-in-error Binding: ClinicalImpressionStatus (required)
code	SΣ	1..1	CodeableConcept	Kind of assessment performed Binding: (unbound) (example)
description	Σ	0..1	string	Why/how the assessment was performed
subject	Σ	1..1	Reference(eHealth Patient \| Group)	Patient or group assessed
context	Σ	1..1	Reference(Encounter \| eHealth EpisodeOfCare)	Encounter or Episode created from
effective[x]	Σ	0..1	dateTime, Period	Time of assessment
date	Σ	0..1	dateTime	When the assessment was documented
assessor	Σ	0..1	Reference(eHealth Practitioner)	The clinician performing the assessment
previous		0..1	Reference(eHealth ClinicalImpression)	Reference to last assessment
problem	Σ	0..*	Reference(Condition \| AllergyIntolerance)	Relevant impressions of patient state
investigation	I	0..*	BackboneElement	One or more sets of investigations (signs, symptions, etc.)
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
ehealth-clinicalimpression-decisionRule		0..*	(Complex)	Decision rule. URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionRule
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
code		1..1	CodeableConcept	A name/code for the set Binding: Investigation Type (example)
item		0..*	Reference(eHealth Observation \| eHealth QuestionnaireResponse \| FamilyMemberHistory \| DiagnosticReport \| RiskAssessment \| ImagingStudy)	Record of a specific investigation
protocol		0..*	uri	Clinical Protocol followed
summary		0..1	string	Summary of the assessment
finding	I	0..*	BackboneElement	Possible or likely findings and diagnoses
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
item[x]		1..1	CodeableConcept, Reference(eHealth Condition \| eHealth Observation)	What was found Binding: ClinicalImpressionFindingCodes (required)
basis		0..1	string	Which investigations support finding
prognosisCodeableConcept		0..*	CodeableConcept	Estimate of likely outcome Binding: Clinical Impression Prognosis (example)
prognosisReference		0..*	Reference(RiskAssessment)	RiskAssessment expressing likely outcome
action		0..*	Reference(ReferralRequest \| eHealth ProcedureRequest \| Procedure \| MedicationRequest \| Appointment)	Action taken as part of assessment procedure
note		0..*	Annotation	Comments made about the ClinicalImpression.
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1	Reference(eHealth Practitioner \| eHealth Patient \| eHealth RelatedPerson), string	Individual responsible for the annotation
time	Σ	0..1	dateTime	When the annotation was made
text		1..1	string	The annotation - text content
Documentation for this format

Terminology Bindings

Path	Name	Conformance	ValueSet
ClinicalImpression.language	Common Languages	extensible	Common Languages
ClinicalImpression.status	ClinicalImpressionStatus	required	ClinicalImpressionStatus
ClinicalImpression.code	?ext	example
ClinicalImpression.investigation.code	Investigation Type	example	Investigation Type
ClinicalImpression.finding.item[x]	ClinicalImpressionFindingCodes	required	ClinicalImpressionFindingCodes
ClinicalImpression.prognosisCodeableConcept	Clinical Impression Prognosis	example	Clinical Impression Prognosis

Constraints

Id	Path	Details	Requirements
dom-2	ClinicalImpression	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-1	ClinicalImpression	If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty()
dom-4	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-3	ClinicalImpression	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource : contained.where(('#'+id in %resource.descendants().reference).not()).empty()
ele-1	ClinicalImpression.investigation	All FHIR elements must have a @value or children : hasValue() \| (children().count() > id.count())
ele-1	ClinicalImpression.finding	All FHIR elements must have a @value or children : hasValue() \| (children().count() > id.count())