eHealth Infrastructure - Local Development build (v2.3.0). See the Directory of published versions
Official URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression | Version: 2.3.0 | |||
Active as of 2022-09-27 | Computable Name: 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.
In scope of the eHealth Infrastructure, the ClinicalImpression resource is used for:
The element code
specifies which of the above uses is the case.
The ClinicalImpression can refer to another ClinicalImpression through the element previous
. It can also refer to measurement resources such as Observation, QuestionnaireResponse and Media through
a number of investigation.item
.
With the extension ehealth-clinicalimpression-decisionContext
, the ClinicalImpression is able to capture decision support invocations such as the automated triaging. This entails:
With the extension ehealth-questionnaireresponse-finding-basis
, the foundation of the overall ClinicalImpression finding can be expressed.
The extension consists of a list, where each element in the list represents an answer significance which was triggered during triage.
Each element includes the following:
The ClinicalImpression instance for the Practitioner assessment can refer to a ClinicalImpression instance of the other types through the element previous
.
The element ehealth-clinicalimpression-decision
contains the Practitioner’s assessment of the measurement/triaging result/decision support result, that is whether the measurement/result is approved and/or approved for publishing in national document sharing.
In case the Practitioner has comments or notes, these can be captured as one or more occurrences of the element note.text
.
The element code
must be set to approved-view
The element ehealth-clinicalimpression-decision
must be set to citizen-view-approved
The element investigation.ehealth-clinicalimpression-viewInvestigationItem
must contain references to the ehealth-views that are approved.
The element investigation.item
must contain references to the QuestionnaireResponses that may use the views.
This indicates to the patient solution that the patient referenced in the subject
element is allowed to use the InterpretedViews for the specified QuestionnaireResponses.
The ClinicalImpression.ehealth-clinicalimpression-careplan must be set when the ClinicalImpression references a resource that somewhere in the reference chain references a CarePlan.
previous
then it must also have the ehealth-clinicalimpression-careplan
element set, referring the same CarePlan as the previous
ClinicalImpression.A ClinicalImpression is not allowed to concern resources from different CarePlans, for example Observations from different CarePlans.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet |
ClinicalImpression.language | preferred | CommonLanguages Max Binding: AllLanguages |
ClinicalImpression.status | required | ClinicalImpressionStatus |
ClinicalImpression.statusReason | example | |
ClinicalImpression.code | required | ClinicalImpressionCodes |
ClinicalImpression.investigation.code | example | InvestigationType |
ClinicalImpression.finding.itemCodeableConcept | required | ClinicalImpressionFindingCodes |
ClinicalImpression.prognosisCodeableConcept | example | ClinicalImpressionPrognosis |