ClinicalImpression

Draft Clinical — Summary

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.

Endpoints

alphahttps://api.dev.ovok.com/fhir/R4/ClinicalImpression

Interaction	Method	Path
Read	GET	/fhir/R4/ClinicalImpression/[id]
Vread	GET	/fhir/R4/ClinicalImpression/[id]/_history/[vid]
Update	PUT	/fhir/R4/ClinicalImpression/[id]
Patch	PATCH	/fhir/R4/ClinicalImpression/[id]
Delete	DELETE	/fhir/R4/ClinicalImpression/[id]
Create	POST	/fhir/R4/ClinicalImpression
Search	GET	/fhir/R4/ClinicalImpression
History	GET	/fhir/R4/ClinicalImpression/[id]/_history

Top-level elements

Element	Type(s)	Cardinality	Description
identifier	Identifier	0..*	Business identifier
status	code	1..1	in-progress | completed | entered-in-error modifier
statusReason	CodeableConcept	0..1	Reason for current status
code	CodeableConcept	0..1	Kind of assessment performed
description	string	0..1	Why/how the assessment was performed
subject	Reference	1..1	Patient or group assessed
encounter	Reference	0..1	Encounter created as part of
effective[x]	dateTime / Period	0..1	Time of assessment
date	dateTime	0..1	When the assessment was documented
assessor	Reference	0..1	The clinician performing the assessment
previous	Reference	0..1	Reference to last assessment
problem	Reference	0..*	Relevant impressions of patient state
investigation	BackboneElement	0..*	One or more sets of investigations (signs, symptoms, etc.)
protocol	uri	0..*	Clinical Protocol followed
summary	string	0..1	Summary of the assessment
finding	BackboneElement	0..*	Possible or likely findings and diagnoses
prognosisCodeableConcept	CodeableConcept	0..*	Estimate of likely outcome
prognosisReference	Reference	0..*	RiskAssessment expressing likely outcome
supportingInfo	Reference	0..*	Information supporting the clinical impression
note	Annotation	0..*	Comments made about the ClinicalImpression

Resource-specific search parameters

Parameter	Type	Description
_compartment	string
_count	string	https://www.hl7.org/fhir/search.html#_count
_elements	string	https://www.hl7.org/fhir/search.html#_elements
_id	string
_lastUpdated	string
_profile	string
_security	string
_sort	string	https://www.hl7.org/fhir/search.html#_sort
_source	string
_summary	string	https://www.hl7.org/fhir/search.html#_summary
_tag	string
_total	string	https://www.hl7.org/fhir/search.html#_total
assessor	string	http://hl7.org/fhir/SearchParameter/ClinicalImpression-assessor
date	string	http://hl7.org/fhir/SearchParameter/clinical-date
encounter	string	http://hl7.org/fhir/SearchParameter/ClinicalImpression-encounter
finding-code	string	http://hl7.org/fhir/SearchParameter/ClinicalImpression-finding-code
finding-ref	string	http://hl7.org/fhir/SearchParameter/ClinicalImpression-finding-ref
identifier	string	http://hl7.org/fhir/SearchParameter/ClinicalImpression-identifier
investigation	string	http://hl7.org/fhir/SearchParameter/ClinicalImpression-investigation
patient	string	http://hl7.org/fhir/SearchParameter/clinical-patient
previous	string	http://hl7.org/fhir/SearchParameter/ClinicalImpression-previous
problem	string	http://hl7.org/fhir/SearchParameter/ClinicalImpression-problem
status	string	http://hl7.org/fhir/SearchParameter/ClinicalImpression-status
subject	string	http://hl7.org/fhir/SearchParameter/ClinicalImpression-subject
supporting-info	string	http://hl7.org/fhir/SearchParameter/ClinicalImpression-supporting-info

Reference

• Official FHIR R4 spec: ClinicalImpression
• Maturity: Draft (FMM 0).