eHealth Infrastructure (v2019.6)

StructureDefinition: ehealth-clinicalimpression

Introduction

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 processing such as triaging and decision support performed on submitted measurement(s)
  • representing a placeholder for subsequent Practitioner assessment. This ClinicalImpression instance is generated when no instance is otherwise created as per automated processing described above.
  • representing an assessment of a Practitioner such as approval and/or approval for publication in national document sharing

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.

Use for Decision Support Result / Triaging Result

With the extension ehealth-clinicalimpression-decisionContext, the ClinicalImpression is able to capture decision support invocations such as the automated triaging. This entails:

  • decision rule identification in the form of a versioned reference to the Library containing the decision rule details including input and output parameter definitions
  • actual parameter values used at invocation, in the form of versioned references to resource(s), for instance input Observation

Use for Practitioner’s Assessment

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.

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 Fri Nov 08 13:01:00 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.
... extension 0..*ExtensionSlice: Unordered, Open by value:url
... ehealth-clinicalimpression-careplan 0..1Reference()The CarePlan
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-careplan
... ehealth-clinicalimpression-decisionContext 0..*Reference()Library and relevant resources used for evaluation
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionContext
... ehealth-clinicalimpression-decision 0..*CodeableConceptapproved | approved-for-sharing
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decision
... code 1..1CodeableConceptBinding: ClinicalImpressionCodes (required)
.... coding 0..*CodingBinding: ClinicalImpressionCodes (required)
... subject 1..1Reference(eHealth Patient) {r}
... context 1..1Reference(eHealth EpisodeOfCare) {r}
... assessor 0..1Reference(eHealth Practitioner) {r}
... previous 0..1Reference(eHealth ClinicalImpression) {r}
... problem 0..*Reference(eHealth Condition | AllergyIntolerance) {r}
... investigation 0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
.... item 0..*Reference(eHealth Observation | eHealth QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) {r}
... finding 0..*BackboneElement
.... item[x] 1..1Binding: ClinicalImpressionFindingCodes (required)
..... itemCodeableConceptCodeableConcept
..... itemReferenceReference(Observation | eHealth Condition)
... prognosisReference 0..*Reference(RiskAssessment) {r}
... action 0..*Reference(ReferralRequest | eHealth ProcedureRequest | Procedure | MedicationRequest | eHealth Appointment) {r}
... note 0..*AnnotationComments made about the ClinicalImpression.
.... author[x] 0..1
..... authorReferenceReference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson)
..... authorStringstring

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)
Max Binding: All Languages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... ehealth-clinicalimpression-careplan I0..1Reference()The CarePlan
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-careplan
... ehealth-clinicalimpression-decisionContext I0..*Reference()Library and relevant resources used for evaluation
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionContext
... ehealth-clinicalimpression-decision I0..*CodeableConceptapproved | approved-for-sharing
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decision
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier
... status ?!Σ1..1codedraft | completed | entered-in-error
Binding: ClinicalImpressionStatus (required)
... code Σ1..1CodeableConceptKind of assessment performed
Binding: ClinicalImpressionCodes (required)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
Binding: ClinicalImpressionCodes (required)
.... text Σ0..1stringPlain text representation of the concept
... description Σ0..1stringWhy/how the assessment was performed
... subject Σ1..1Reference(eHealth Patient) {r}Patient or group assessed
... context Σ1..1Reference(eHealth EpisodeOfCare) {r}Encounter or Episode created from
... effective[x] Σ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... date Σ0..1dateTimeWhen the assessment was documented
... assessor Σ0..1Reference(eHealth Practitioner) {r}The clinician performing the assessment
... previous 0..1Reference(eHealth ClinicalImpression) {r}Reference to last assessment
... problem Σ0..*Reference(eHealth Condition | AllergyIntolerance) {r}Relevant impressions of patient state
... investigation I0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... 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) {r}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..1What was found
Binding: ClinicalImpressionFindingCodes (required)
..... itemCodeableConceptCodeableConcept
..... itemReferenceReference(Observation | eHealth Condition)
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate of likely outcome
Binding: Clinical Impression Prognosis (example)
... prognosisReference 0..*Reference(RiskAssessment) {r}RiskAssessment expressing likely outcome
... action 0..*Reference(ReferralRequest | eHealth ProcedureRequest | Procedure | MedicationRequest | eHealth Appointment) {r}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..1Individual responsible for the annotation
..... authorReferenceReference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson)
..... authorStringstring
.... 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.
... extension 0..*ExtensionSlice: Unordered, Open by value:url
... ehealth-clinicalimpression-careplan 0..1Reference()The CarePlan
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-careplan
... ehealth-clinicalimpression-decisionContext 0..*Reference()Library and relevant resources used for evaluation
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionContext
... ehealth-clinicalimpression-decision 0..*CodeableConceptapproved | approved-for-sharing
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decision
... code 1..1CodeableConceptBinding: ClinicalImpressionCodes (required)
.... coding 0..*CodingBinding: ClinicalImpressionCodes (required)
... subject 1..1Reference(eHealth Patient) {r}
... context 1..1Reference(eHealth EpisodeOfCare) {r}
... assessor 0..1Reference(eHealth Practitioner) {r}
... previous 0..1Reference(eHealth ClinicalImpression) {r}
... problem 0..*Reference(eHealth Condition | AllergyIntolerance) {r}
... investigation 0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
.... item 0..*Reference(eHealth Observation | eHealth QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) {r}
... finding 0..*BackboneElement
.... item[x] 1..1Binding: ClinicalImpressionFindingCodes (required)
..... itemCodeableConceptCodeableConcept
..... itemReferenceReference(Observation | eHealth Condition)
... prognosisReference 0..*Reference(RiskAssessment) {r}
... action 0..*Reference(ReferralRequest | eHealth ProcedureRequest | Procedure | MedicationRequest | eHealth Appointment) {r}
... note 0..*AnnotationComments made about the ClinicalImpression.
.... author[x] 0..1
..... authorReferenceReference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson)
..... authorStringstring

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)
Max Binding: All Languages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... ehealth-clinicalimpression-careplan I0..1Reference()The CarePlan
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-careplan
... ehealth-clinicalimpression-decisionContext I0..*Reference()Library and relevant resources used for evaluation
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionContext
... ehealth-clinicalimpression-decision I0..*CodeableConceptapproved | approved-for-sharing
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decision
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier
... status ?!Σ1..1codedraft | completed | entered-in-error
Binding: ClinicalImpressionStatus (required)
... code Σ1..1CodeableConceptKind of assessment performed
Binding: ClinicalImpressionCodes (required)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*CodingCode defined by a terminology system
Binding: ClinicalImpressionCodes (required)
.... text Σ0..1stringPlain text representation of the concept
... description Σ0..1stringWhy/how the assessment was performed
... subject Σ1..1Reference(eHealth Patient) {r}Patient or group assessed
... context Σ1..1Reference(eHealth EpisodeOfCare) {r}Encounter or Episode created from
... effective[x] Σ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... date Σ0..1dateTimeWhen the assessment was documented
... assessor Σ0..1Reference(eHealth Practitioner) {r}The clinician performing the assessment
... previous 0..1Reference(eHealth ClinicalImpression) {r}Reference to last assessment
... problem Σ0..*Reference(eHealth Condition | AllergyIntolerance) {r}Relevant impressions of patient state
... investigation I0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... 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) {r}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..1What was found
Binding: ClinicalImpressionFindingCodes (required)
..... itemCodeableConceptCodeableConcept
..... itemReferenceReference(Observation | eHealth Condition)
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate of likely outcome
Binding: Clinical Impression Prognosis (example)
... prognosisReference 0..*Reference(RiskAssessment) {r}RiskAssessment expressing likely outcome
... action 0..*Reference(ReferralRequest | eHealth ProcedureRequest | Procedure | MedicationRequest | eHealth Appointment) {r}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..1Individual responsible for the annotation
..... authorReferenceReference(eHealth Practitioner | eHealth Patient | eHealth RelatedPerson)
..... authorStringstring
.... time Σ0..1dateTimeWhen the annotation was made
.... text 1..1stringThe annotation - text content

doco Documentation for this format

 

Terminology Bindings

PathConformanceValueSet
ClinicalImpression.languageextensibleCommon Languages
Max Binding: All Languages
ClinicalImpression.statusrequiredClinicalImpressionStatus
ClinicalImpression.coderequiredClinicalImpressionCodes
ClinicalImpression.code.codingrequiredClinicalImpressionCodes
ClinicalImpression.investigation.codeexampleInvestigation Type
ClinicalImpression.finding.item[x]requiredClinicalImpressionFindingCodes
ClinicalImpression.prognosisCodeableConceptexampleClinical 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.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1ClinicalImpression.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClinicalImpression.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1ClinicalImpression.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClinicalImpression.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1ClinicalImpression.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClinicalImpression.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1ClinicalImpression.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
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())
.