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.

Required if CarePlan is known

1. The ClinicalImpression.ehealth-clinicalimpression-careplan must be set when the ClinicalImpression references a resource that somewhere in the reference chain references a CarePlan.

   • For example, when a Practitioner assessment ClinicalImpression refers another ClinicalImpression through the element previous then it must also have the ehealth-clinicalimpression-careplan element set, referring the same CarePlan as the previous ClinicalImpression.

2. A ClinicalImpression is not allowed to concern resources from different CarePlans, for example Observations from different CarePlans.