ClinicalImpression

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.

These interaction paths describe standard FHIR R4 patterns. Availability can depend on the API capabilities enabled for your Ovok project.

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	Cardinality	Description
id	string	0..1	Logical id of this artifact
meta	Meta	0..1	Metadata about the resource
implicitRules	uri	0..1	A set of rules under which this content was created
language	code	0..1	Language of the resource content
text	Narrative	0..1	Text summary of the resource, for human interpretation
contained	Resource	0..*	Contained, inline Resources
extension	Extension	0..*	Additional content defined by implementations
modifierExtension	Extension	0..*	Extensions that cannot be ignored
identifier	Identifier	0..*	Business identifier
status	code	1..1	in-progress | completed | entered-in-error
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
assessor	reference	The clinician performing the assessment
date	date	Multiple Resources: AllergyIntolerance: Date first version of the resource instance was recorded ; CarePlan: Time period plan covers ; CareTeam: Time period team covers ; ClinicalImpression: When the assessment was documented ; Composition: Composition editing time ; Consent: When this Consent was created or indexed ; DiagnosticReport: The clinically relevant time of the report ; Encounter: A date within the period the Encounter lasted ; EpisodeOfCare: The provided date search value falls within the episode of care's period ; FamilyMemberHistory: When history was recorded or last updated ; Flag: Time period when flag is active ; Immunization: Vaccination (non)-Administration Date ; List: When the list was prepared ; Observation: Obtained date/time. If the obtained element is a period, a date that falls in the period ; Procedure: When the procedure was performed ; RiskAssessment: When was assessment made? ; SupplyRequest: When the request was made
encounter	reference	Encounter created as part of
finding-code	token	What was found
finding-ref	reference	What was found
identifier	token	Business identifier
investigation	reference	Record of a specific investigation
patient	reference	Multiple Resources: AllergyIntolerance: Who the sensitivity is for ; CarePlan: Who the care plan is for ; CareTeam: Who care team is for ; ClinicalImpression: Patient or group assessed ; Composition: Who and/or what the composition is about ; Condition: Who has the condition? ; Consent: Who the consent applies to ; DetectedIssue: Associated patient ; DeviceRequest: Individual the service is ordered for ; DeviceUseStatement: Search by subject - a patient ; DiagnosticReport: The subject of the report if a patient ; DocumentManifest: The subject of the set of documents ; DocumentReference: Who/what is the subject of the document ; Encounter: The patient or group present at the encounter ; EpisodeOfCare: The patient who is the focus of this episode of care ; FamilyMemberHistory: The identity of a subject to list family member history items for ; Flag: The identity of a subject to list flags for ; Goal: Who this goal is intended for ; ImagingStudy: Who the study is about ; Immunization: The patient for the vaccination record ; List: If all resources have the same subject ; MedicationAdministration: The identity of a patient to list administrations for ; MedicationDispense: The identity of a patient to list dispenses for ; MedicationRequest: Returns prescriptions for a specific patient ; MedicationStatement: Returns statements for a specific patient. ; NutritionOrder: The identity of the person who requires the diet, formula or nutritional supplement ; Observation: The subject that the observation is about (if patient) ; Procedure: Search by subject - a patient ; RiskAssessment: Who/what does assessment apply to? ; ServiceRequest: Search by subject - a patient ; SupplyDelivery: Patient for whom the item is supplied ; VisionPrescription: The identity of a patient to list dispenses for
previous	reference	Reference to last assessment
problem	reference	Relevant impressions of patient state
status	token	in-progress | completed | entered-in-error
subject	reference	Patient or group assessed
supporting-info	reference	Information supporting the clinical impression

Reference

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