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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 Tue Feb 04 09:11:17 UTC 2020 as a draft by ehealth.sundhed.dk.

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

 

Terminology Bindings

Path	Conformance	ValueSet
ClinicalImpression.language	extensible	Common Languages Max Binding: All Languages
ClinicalImpression.status	required	ClinicalImpressionStatus
ClinicalImpression.code	required	ClinicalImpressionCodes
ClinicalImpression.code.coding	required	ClinicalImpressionCodes
ClinicalImpression.investigation.code	example	Investigation Type
ClinicalImpression.finding.item[x]	required	ClinicalImpressionFindingCodes
ClinicalImpression.prognosisCodeableConcept	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.extension:careplan	All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count())
ext-1	ClinicalImpression.extension:careplan	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	ClinicalImpression.extension:decisionContext	All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count())
ext-1	ClinicalImpression.extension:decisionContext	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	ClinicalImpression.extension:decision	All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count())
ext-1	ClinicalImpression.extension:decision	Must have either extensions or value[x], not both : extension.exists() != value.exists()
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())

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