eHealth Infrastructure (v1.0.0)

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*A record of a clinical assessment performed to determine what problem(s) may affect the patient.
... code S1..1CodeableConcept
... subject 1..1Reference(eHealth Patient | Group)
... context 1..1Reference(Encounter | eHealth EpisodeOfCare)
... assessor 0..1Reference(eHealth Practitioner)
... previous 0..1Reference(eHealth ClinicalImpression)
... investigation 0..*BackboneElementOne 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..1CodeableConcept, Reference(eHealth Condition | eHealth Observation)Binding: ClinicalImpressionFindingCodes (required)
... action 0..*Reference(ReferralRequest | eHealth ProcedureRequest | Procedure | MedicationRequest | Appointment)
... note 0..*AnnotationComments made about the ClinicalImpression.
.... author[x] 0..1Reference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson), string

doco Documentation for this format

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression I0..*A record of a clinical assessment performed to determine what problem(s) may affect the patient.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier
... status ?!Σ1..1codedraft | completed | entered-in-error
Binding: ClinicalImpressionStatus (required)
... code SΣ1..1CodeableConceptKind of assessment performed
Binding: (unbound) (example)
... description Σ0..1stringWhy/how the assessment was performed
... subject Σ1..1Reference(eHealth Patient | Group)Patient or group assessed
... context Σ1..1Reference(Encounter | eHealth EpisodeOfCare)Encounter or Episode created from
... effective[x] Σ0..1dateTime, PeriodTime of assessment
... date Σ0..1dateTimeWhen the assessment was documented
... assessor Σ0..1Reference(eHealth Practitioner)The clinician performing the assessment
... previous 0..1Reference(eHealth ClinicalImpression)Reference to last assessment
... problem Σ0..*Reference(Condition | AllergyIntolerance)Relevant impressions of patient state
... investigation I0..*BackboneElementOne or more sets of investigations (signs, symptions, etc.)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... ehealth-clinicalimpression-decisionRule 0..*(Complex)Decision rule.
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionRule
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code 1..1CodeableConceptA 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..*uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... finding I0..*BackboneElementPossible or likely findings and diagnoses
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... item[x] 1..1CodeableConcept, Reference(eHealth Condition | eHealth Observation)What was found
Binding: ClinicalImpressionFindingCodes (required)
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate 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..*AnnotationComments made about the ClinicalImpression.
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... author[x] Σ0..1Reference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson), stringIndividual responsible for the annotation
.... time Σ0..1dateTimeWhen the annotation was made
.... text 1..1stringThe annotation - text content

doco Documentation for this format

Differential View

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*A record of a clinical assessment performed to determine what problem(s) may affect the patient.
... code S1..1CodeableConcept
... subject 1..1Reference(eHealth Patient | Group)
... context 1..1Reference(Encounter | eHealth EpisodeOfCare)
... assessor 0..1Reference(eHealth Practitioner)
... previous 0..1Reference(eHealth ClinicalImpression)
... investigation 0..*BackboneElementOne 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..1CodeableConcept, Reference(eHealth Condition | eHealth Observation)Binding: ClinicalImpressionFindingCodes (required)
... action 0..*Reference(ReferralRequest | eHealth ProcedureRequest | Procedure | MedicationRequest | Appointment)
... note 0..*AnnotationComments made about the ClinicalImpression.
.... author[x] 0..1Reference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson), string

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression I0..*A record of a clinical assessment performed to determine what problem(s) may affect the patient.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier
... status ?!Σ1..1codedraft | completed | entered-in-error
Binding: ClinicalImpressionStatus (required)
... code SΣ1..1CodeableConceptKind of assessment performed
Binding: (unbound) (example)
... description Σ0..1stringWhy/how the assessment was performed
... subject Σ1..1Reference(eHealth Patient | Group)Patient or group assessed
... context Σ1..1Reference(Encounter | eHealth EpisodeOfCare)Encounter or Episode created from
... effective[x] Σ0..1dateTime, PeriodTime of assessment
... date Σ0..1dateTimeWhen the assessment was documented
... assessor Σ0..1Reference(eHealth Practitioner)The clinician performing the assessment
... previous 0..1Reference(eHealth ClinicalImpression)Reference to last assessment
... problem Σ0..*Reference(Condition | AllergyIntolerance)Relevant impressions of patient state
... investigation I0..*BackboneElementOne or more sets of investigations (signs, symptions, etc.)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... ehealth-clinicalimpression-decisionRule 0..*(Complex)Decision rule.
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionRule
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code 1..1CodeableConceptA 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..*uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... finding I0..*BackboneElementPossible or likely findings and diagnoses
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... item[x] 1..1CodeableConcept, Reference(eHealth Condition | eHealth Observation)What was found
Binding: ClinicalImpressionFindingCodes (required)
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate 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..*AnnotationComments made about the ClinicalImpression.
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... author[x] Σ0..1Reference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson), stringIndividual responsible for the annotation
.... time Σ0..1dateTimeWhen the annotation was made
.... text 1..1stringThe annotation - text content

doco Documentation for this format

 

Terminology Bindings

PathNameConformanceValueSet
ClinicalImpression.languageCommon LanguagesextensibleCommon Languages
ClinicalImpression.statusClinicalImpressionStatusrequiredClinicalImpressionStatus
ClinicalImpression.code?extexample
ClinicalImpression.investigation.codeInvestigation TypeexampleInvestigation Type
ClinicalImpression.finding.item[x]ClinicalImpressionFindingCodesrequiredClinicalImpressionFindingCodes
ClinicalImpression.prognosisCodeableConceptClinical Impression PrognosisexampleClinical Impression Prognosis

Constraints

IdPathDetailsRequirements
dom-2ClinicalImpressionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-1ClinicalImpressionIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-4ClinicalImpressionIf 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-3ClinicalImpressionIf 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-1ClinicalImpression.investigationAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ele-1ClinicalImpression.findingAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
.