eHealth Infrastructure (v2020.1)

StructureDefinition: ehealth-clinicalimpression - Detailed Descriptions

Definitions for the ehealth-clinicalimpression Profile.

1. ClinicalImpression
Definition

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.

Control0..*
InvariantsDefined on this element
dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative (: contained.text.empty())
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
dom-3: 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())
dom-4: 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())
2. ClinicalImpression.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

3. ClinicalImpression.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Control0..1
TypeMeta
4. ClinicalImpression.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

5. ClinicalImpression.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language.
The codes SHALL be taken from Common Languages; other codes may be used where these codes are not suitable
Max Binding: All Languages
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

6. ClinicalImpression.text
Definition

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.

7. ClinicalImpression.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

8. ClinicalImpression.extension
Definition

An Extension

Control0..*
TypeExtension
SlicingThis element introduces a set of slices on ClinicalImpression.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
9. ClinicalImpression.extension:careplan
SliceNamecareplan
Definition

An Extension

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(clinicalimpression-careplan) (Extension Type: Reference)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
10. ClinicalImpression.extension:decisionContext
SliceNamedecisionContext
Definition

Optional Extension Element - found in all resources.

Control0..* This element is affected by the following invariants: ele-1
TypeExtension(decisionContext) (Extension Type: Reference)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
11. ClinicalImpression.extension:decision
SliceNamedecision
Definition

Optional Extension Element - found in all resources.

Control0..* This element is affected by the following invariants: ele-1
TypeExtension(Extension-ehealth-clinicalimpression-decision) (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
12. ClinicalImpression.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

13. ClinicalImpression.identifier
Definition

A unique identifier assigned to the clinical impression that remains consistent regardless of what server the impression is stored on.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
14. ClinicalImpression.status
Definition

Identifies the workflow status of the assessment.

Control1..1
BindingThe workflow state of a clinical impression.
The codes SHALL be taken from ClinicalImpressionStatus
Typecode
Is Modifiertrue
Comments

This element is labeled as a modifier because the status contains the code entered-in-error that marks the clinical impression as not currently valid.

15. ClinicalImpression.code
Definition

Categorizes the type of clinical assessment performed.

Control1..1
BindingThe codes SHALL be taken from ClinicalImpressionCodes
TypeCodeableConcept
Alternate Namestype
Comments

This is present as a place-holder only and may be removed based on feedback/work group opinion.

16. ClinicalImpression.code.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
17. ClinicalImpression.code.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingThis element introduces a set of slices on ClinicalImpression.code.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
18. ClinicalImpression.code.coding
Definition

A reference to a code defined by a terminology system.

Control0..*
BindingIdentifies categories of clinical impressions. This is a place-holder only. It may be removed
The codes SHALL be taken from ClinicalImpressionCodes
TypeCoding
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

19. ClinicalImpression.code.text
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Control0..1
Typestring
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

20. ClinicalImpression.description
Definition

A summary of the context and/or cause of the assessment - why / where was it performed, and what patient events/status prompted it.

Control0..1
Typestring
21. ClinicalImpression.subject
Definition

The patient or group of individuals assessed as part of this record.

Control1..1
TypeReference(ehealth-patient)
Requirements

Group is typically for veterinary and/or public health purposes.

22. ClinicalImpression.context
Definition

The encounter or episode of care this impression was created as part of.

Control1..1
TypeReference(ehealth-episodeofcare)
Alternate Namesencounter
23. ClinicalImpression.effective[x]
Definition

The point in time or period over which the subject was assessed.

Control0..1
TypeChoice of: dateTime, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Comments

This SHOULD be accurate to at least the minute, though some assessments only have a known date.

24. ClinicalImpression.date
Definition

Indicates when the documentation of the assessment was complete.

Control0..1
TypedateTime
25. ClinicalImpression.assessor
Definition

The clinician performing the assessment.

Control0..1
TypeReference(ehealth-practitioner)
Requirements

constraint: must be present when code designates practitioner's assessment

26. ClinicalImpression.previous
Definition

A reference to the last assesment that was conducted bon this patient. Assessments are often/usually ongoing in nature; a care provider (practitioner or team) will make new assessments on an ongoing basis as new data arises or the patient's conditions changes.

Control0..1
TypeReference(ehealth-clinicalimpression)
Comments

It is always likely that multiple previous assessments exist for a patient. The point of quoting a previous assessment is that this assessment is relative to it (see resolved).

27. ClinicalImpression.problem
Definition

This a list of the relevant problems/conditions for a patient.

Control0..*
TypeReference(ehealth-condition | AllergyIntolerance)
Comments

e.g. The patient is a pregnant, and cardiac congestive failure, ‎Adenocarcinoma, and is allergic to penicillin.

28. ClinicalImpression.investigation
Definition

One or more sets of investigations (signs, symptions, etc.). The actual grouping of investigations vary greatly depending on the type and context of the assessment. These investigations may include data generated during the assessment process, or data previously generated and recorded that is pertinent to the outcomes.

Control0..*
TypeBackboneElement
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
29. ClinicalImpression.investigation.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
30. ClinicalImpression.investigation.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

31. ClinicalImpression.investigation.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

32. ClinicalImpression.investigation.code
Definition

A name/code for the group ("set") of investigations. Typically, this will be something like "signs", "symptoms", "clinical", "diagnostic", but the list is not constrained, and others such groups such as (exposure|family|travel|nutitirional) history may be used.

Control1..1
BindingA name/code for a set of investigations.
For example codes, see Investigation Type
TypeCodeableConcept
33. ClinicalImpression.investigation.item
Definition

A record of a specific investigation that was undertaken.

Control0..*
TypeReference(ehealth-observation | ehealth-questionnaireresponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy)
Comments

Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used.

34. ClinicalImpression.protocol
Definition

Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.

Control0..*
Typeuri
35. ClinicalImpression.summary
Definition

A text summary of the investigations and the diagnosis.

Control0..1
Typestring
36. ClinicalImpression.finding
Definition

Specific findings or diagnoses that was considered likely or relevant to ongoing treatment.

Control0..*
TypeBackboneElement
Requirements

constraint: must be present when code designates practitioner's assessment

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() | (children().count() > id.count()))
37. ClinicalImpression.finding.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
38. ClinicalImpression.finding.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

39. ClinicalImpression.finding.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

40. ClinicalImpression.finding.item[x]
Definition

Specific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditions.

Control1..1
BindingThe codes SHALL be taken from ClinicalImpressionFindingCodes
TypeChoice of: CodeableConcept, Reference(Observation | ehealth-condition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
41. ClinicalImpression.finding.basis
Definition

Which investigations support finding or diagnosis.

Control0..1
Typestring
42. ClinicalImpression.prognosisCodeableConcept
Definition

Estimate of likely outcome.

Control0..*
BindingPrognosis or outlook findings
For example codes, see Clinical Impression Prognosis
TypeCodeableConcept
43. ClinicalImpression.prognosisReference
Definition

RiskAssessment expressing likely outcome.

Control0..*
TypeReference(RiskAssessment)
44. ClinicalImpression.action
Definition

Action taken as part of assessment procedure.

Control0..*
TypeReference(ReferralRequest | ehealth-procedurerequest | Procedure | MedicationRequest | ehealth-appointment)
Comments

Actions recommended as a result of the impression should not be captured using the 'action' element.

45. ClinicalImpression.note
Definition

Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear.

Control0..*
TypeAnnotation
Comments

Don't use this element for content that should more properly appear as one of the specific elements of the impression.

46. ClinicalImpression.note.id
Definition

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Control0..1
Typestring
47. ClinicalImpression.note.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

SlicingThis element introduces a set of slices on ClinicalImpression.note.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
48. ClinicalImpression.note.author[x]
Definition

The individual responsible for making the annotation.

Control0..1
TypeChoice of: Reference(ehealth-practitioner | ehealth-patient | ehealth-relatedperson), string
[x] NoteSee Choice of Data Types for further information about how to use [x]
49. ClinicalImpression.note.time
Definition

Indicates when this particular annotation was made.

Control0..1
TypedateTime
50. ClinicalImpression.note.text
Definition

The text of the annotation.

Control1..1
Typestring