ClinicalImpression

Trial Use 1 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

devhttps://api.sandbox.ovok.com/fhir/R5/ClinicalImpression

Interaction	Method	Path
Read	GET	/fhir/R5/ClinicalImpression/[id]
Vread	GET	/fhir/R5/ClinicalImpression/[id]/_history/[vid]
Update	PUT	/fhir/R5/ClinicalImpression/[id]
Patch	PATCH	/fhir/R5/ClinicalImpression/[id]
Delete	DELETE	/fhir/R5/ClinicalImpression/[id]
Create	POST	/fhir/R5/ClinicalImpression
Search	GET	/fhir/R5/ClinicalImpression?...
History	GET	/fhir/R5/ClinicalImpression/[id]/_history
Type-history	GET	/fhir/R5/ClinicalImpression/_history

Top-level elements

Element	Type(s)	Cardinality	Description
identifier	Identifier	0..*	Business identifier
status	code	1..1	preparation
statusReason	CodeableConcept	0..1	Reason for current status
description	string	0..1	Why/how the assessment was performed
subject	Reference	1..1	Patient or group assessed
encounter	Reference	0..1	The Encounter during which this ClinicalImpression was created
effective[x]	dateTime / Period	0..1	Time of assessment
date	dateTime	0..1	When the assessment was documented
performer	Reference	0..1	The clinician performing the assessment
previous	Reference	0..1	Reference to last assessment
problem	Reference	0..*	Relevant impressions of patient state
changePattern	CodeableConcept	0..1	Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change
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
date	date	When the event occurred
encounter	reference	Encounter related to the activity recorded in the AuditEvent
finding-code	token	Reference to a concept (by class)
finding-ref	reference	Reference to a resource (by instance)
identifier	token	Account number
patient	reference	The entity that caused the expenses
performer	reference	The clinician performing the assessment
previous	reference	Reference to last assessment
problem	reference	Relevant impressions of patient state
status	token	preparation
subject	reference	Patient or group assessed
supporting-info	reference	Information supporting the clinical impression

Reference

• Official FHIR R5 spec: ClinicalImpression
• Maturity: Trial Use 1 (FMM 1).