eHealth Infrastructure
3.1.0 - release

This page is part of the FUT Infrastructure (v3.1.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: ehealth-clinicalimpression

Official URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression Version: 3.1.0
Active as of 2024-07-01 Computable Name: 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
  • representing an approval for using an InterpretedView (ehealth-view) for QuestionnaireResponses

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 Triaging Result Basis

With the extension ehealth-questionnaireresponse-finding-basis, the foundation of the overall ClinicalImpression finding can be expressed.

The extension consists of a list, where each element in the list represents an answer significance which was triggered during triage.

Each element includes the following:

  • linkId of the question/answer pair which triggered the finding basis
  • the value of the answer. This element is not populated if the answer significance condition operator is “exists”, and the condition value is false.
  • the clinical impression finding code corresponding to the triggered answer significance
  • the triggered ehealth-questionnaire-answerSignificance

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.

Use for approving InterpretedView

The element code must be set to approved-view

The element ehealth-clinicalimpression-decision must be set to citizen-view-approved

The element investigation.ehealth-clinicalimpression-viewInvestigationItem must contain references to the ehealth-views that are approved.

The element investigation.item must contain references to the QuestionnaireResponses that may use the views.

This indicates to the patient solution that the patient referenced in the subject element is allowed to use the InterpretedViews for the specified QuestionnaireResponses.

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.

Used for manual approval of measurement sharing

The element assessorOrganization is automatically set by the infrastructure to reflect the organizational context of the assessor who performed the assessment, when a ClinicalImpression is created to indicate the approval of document sharing.

  • In the case of a manual approval, the element assessorOrganization will automatically be set to the organizational context of the Practitioner who performed the assessment.
  • In the case of an automated approval, the element assessorOrganization will automatically be set to the CarePlan.author if possible, else it will be the EpisodeOfCare.caremanagerOrganization.

Usage:

Formal Views of Profile Content

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

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression ClinicalImpression
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... assessorOrganization 0..1 Reference(ehealth-organization) {r} Assessors Organization
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-assessor-organization
.... carePlan 0..1 Reference(ehealth-careplan) {r} The Careplan
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-careplan
.... decisionContext 0..* Reference(Parameters) {r, c} Library and relevant resources used for evaluation
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionContext
.... decision 0..* CodeableConcept approved | approved-for-sharing
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decision
Binding: ClinicalImpression Decision Codes (required)
.... episodeOfCare 1..1 Reference(EpisodeOfCare) Associated Encounter episode of care
URL: http://hl7.org/fhir/StructureDefinition/workflow-episodeOfCare
.... findingBasis 0..* (Complex) The basis for a clinical impression finding
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaireresponse-finding-basis
... code 1..1 CodeableConcept Kind of assessment performed
Binding: Clinical Impression Codes (required)
... subject 1..1 Reference(ehealth-patient) {r} Patient or group assessed
... previous 0..1 Reference(ehealth-clinicalimpression) {r} Reference to last assessment
... problem 0..* Reference(ehealth-condition | AllergyIntolerance) {r} Relevant impressions of patient state
... investigation
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... viewInvestigationItem 0..* Reference(ehealth-view) {r} View item
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-viewInvestigationItem
.... code 1..1 CodeableConcept A name/code for the set
Binding: http://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes (example)
.... item 0..* Reference(ehealth-media | ehealth-observation | ehealth-questionnaireresponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) {r} Record of a specific investigation
... finding
.... itemCodeableConcept 0..1 CodeableConcept What was found
Binding: ClinicalImpression Finding Codes (required)
.... itemReference 0..1 Reference(Observation | ehealth-condition) What was found
... prognosisReference 0..* Reference(RiskAssessment) {r} RiskAssessment expressing likely outcome
... note
.... Slices for author[x] 0..1 Reference(Practitioner | Patient | RelatedPerson | Organization), string Individual responsible for the annotation
Slice: Unordered, Open by type:$this
..... author[x]:authorReference 0..1 Reference(ehealth-practitioner | ehealth-patient | ehealth-relatedperson) Individual responsible for the annotation
..... author[x]:authorString 0..1 string Individual responsible for the annotation

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClinicalImpression.coderequiredClinicalImpressionCodes (a valid code from ClinicalImpression Codes)
http://ehealth.sundhed.dk/vs/clinicalimpression-codes
from this IG
ClinicalImpression.investigation.codeexamplehttp://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes
http://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes
ClinicalImpression.finding.itemCodeableConceptrequiredClinicalImpressionFindingCodes
http://ehealth.sundhed.dk/vs/clinicalimpression-finding-codes
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... assessorOrganization 0..1 Reference(ehealth-organization) {r} Assessors Organization
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-assessor-organization
.... carePlan 0..1 Reference(ehealth-careplan) {r} The Careplan
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-careplan
.... decisionContext 0..* Reference(Parameters) {r, c} Library and relevant resources used for evaluation
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionContext
.... decision 0..* CodeableConcept approved | approved-for-sharing
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decision
Binding: ClinicalImpression Decision Codes (required)
.... episodeOfCare 1..1 Reference(EpisodeOfCare) Associated Encounter episode of care
URL: http://hl7.org/fhir/StructureDefinition/workflow-episodeOfCare
.... findingBasis 0..* (Complex) The basis for a clinical impression finding
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaireresponse-finding-basis
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... code Σ 1..1 CodeableConcept Kind of assessment performed
Binding: Clinical Impression Codes (required)
... subject Σ 1..1 Reference(ehealth-patient) {r} Patient or group assessed
... assessor Σ 0..1 Reference(ehealth-practitioner) {r} The clinician performing the assessment
... previous 0..1 Reference(ehealth-clinicalimpression) {r} Reference to last assessment
... problem Σ 0..* Reference(ehealth-condition | AllergyIntolerance) {r} Relevant impressions of patient state
... prognosisReference 0..* Reference(RiskAssessment) {r} RiskAssessment expressing likely outcome

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClinicalImpression.statusrequiredClinicalImpressionStatus
http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1
from the FHIR Standard
ClinicalImpression.coderequiredClinicalImpressionCodes (a valid code from ClinicalImpression Codes)
http://ehealth.sundhed.dk/vs/clinicalimpression-codes
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... assessorOrganization 0..1 Reference(ehealth-organization) {r} Assessors Organization
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-assessor-organization
.... carePlan 0..1 Reference(ehealth-careplan) {r} The Careplan
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-careplan
.... decisionContext 0..* Reference(Parameters) {r, c} Library and relevant resources used for evaluation
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionContext
.... decision 0..* CodeableConcept approved | approved-for-sharing
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decision
Binding: ClinicalImpression Decision Codes (required)
.... episodeOfCare 1..1 Reference(EpisodeOfCare) Associated Encounter episode of care
URL: http://hl7.org/fhir/StructureDefinition/workflow-episodeOfCare
.... findingBasis 0..* (Complex) The basis for a clinical impression finding
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaireresponse-finding-basis
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier
... status ?!Σ 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.

... statusReason 0..1 CodeableConcept Reason for current status
Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.

... code Σ 1..1 CodeableConcept Kind of assessment performed
Binding: Clinical Impression Codes (required)
... description Σ 0..1 string Why/how the assessment was performed
... subject Σ 1..1 Reference(ehealth-patient) {r} Patient or group assessed
... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
... effective[x] Σ 0..1 Time of assessment
.... effectiveDateTime dateTime
.... effectivePeriod Period
... date Σ 0..1 dateTime When the assessment was documented
... assessor Σ 0..1 Reference(ehealth-practitioner) {r} The clinician performing the assessment
... previous 0..1 Reference(ehealth-clinicalimpression) {r} Reference to last assessment
... problem Σ 0..* Reference(ehealth-condition | AllergyIntolerance) {r} Relevant impressions of patient state
... investigation 0..* BackboneElement One or more sets of investigations (signs, symptoms, etc.)
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... viewInvestigationItem 0..* Reference(ehealth-view) {r} View item
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-viewInvestigationItem
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept A name/code for the set
Binding: http://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes (example)
.... item 0..* Reference(ehealth-media | ehealth-observation | ehealth-questionnaireresponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) {r} Record of a specific investigation
... protocol 0..* uri Clinical Protocol followed
... summary 0..1 string Summary of the assessment
... finding 0..* BackboneElement Possible or likely findings and diagnoses
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1 CodeableConcept What was found
Binding: ClinicalImpression Finding Codes (required)
.... itemReference 0..1 Reference(Observation | ehealth-condition) What was found
.... basis 0..1 string Which investigations support finding
... prognosisCodeableConcept 0..* CodeableConcept Estimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.


... prognosisReference 0..* Reference(RiskAssessment) {r} RiskAssessment expressing likely outcome
... supportingInfo 0..* Reference(Resource) Information supporting the clinical impression
... note 0..* Annotation Comments made about the ClinicalImpression
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for author[x] Σ 0..1 Individual responsible for the annotation
Slice: Unordered, Closed by type:$this
..... authorReference Reference(Practitioner | Patient | RelatedPerson | Organization)
..... authorString string
..... author[x]:authorReference Σ 0..1 Reference(ehealth-practitioner | ehealth-patient | ehealth-relatedperson) Individual responsible for the annotation
..... author[x]:authorString Σ 0..1 string Individual responsible for the annotation
.... time Σ 0..1 dateTime When the annotation was made
.... text Σ 1..1 markdown The annotation - text content (as markdown)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClinicalImpression.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClinicalImpression.statusrequiredClinicalImpressionStatus
http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1
from the FHIR Standard
ClinicalImpression.statusReasonexample
ClinicalImpression.coderequiredClinicalImpressionCodes (a valid code from ClinicalImpression Codes)
http://ehealth.sundhed.dk/vs/clinicalimpression-codes
from this IG
ClinicalImpression.investigation.codeexamplehttp://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes
http://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes
ClinicalImpression.finding.itemCodeableConceptrequiredClinicalImpressionFindingCodes
http://ehealth.sundhed.dk/vs/clinicalimpression-finding-codes
from this IG
ClinicalImpression.prognosisCodeableConceptexampleClinicalImpressionPrognosis
http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis
from the FHIR Standard

This structure is derived from ClinicalImpression

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of ClinicalImpression.note.author[x]

Differential View

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression ClinicalImpression
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... assessorOrganization 0..1 Reference(ehealth-organization) {r} Assessors Organization
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-assessor-organization
.... carePlan 0..1 Reference(ehealth-careplan) {r} The Careplan
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-careplan
.... decisionContext 0..* Reference(Parameters) {r, c} Library and relevant resources used for evaluation
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionContext
.... decision 0..* CodeableConcept approved | approved-for-sharing
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decision
Binding: ClinicalImpression Decision Codes (required)
.... episodeOfCare 1..1 Reference(EpisodeOfCare) Associated Encounter episode of care
URL: http://hl7.org/fhir/StructureDefinition/workflow-episodeOfCare
.... findingBasis 0..* (Complex) The basis for a clinical impression finding
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaireresponse-finding-basis
... code 1..1 CodeableConcept Kind of assessment performed
Binding: Clinical Impression Codes (required)
... subject 1..1 Reference(ehealth-patient) {r} Patient or group assessed
... previous 0..1 Reference(ehealth-clinicalimpression) {r} Reference to last assessment
... problem 0..* Reference(ehealth-condition | AllergyIntolerance) {r} Relevant impressions of patient state
... investigation
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... viewInvestigationItem 0..* Reference(ehealth-view) {r} View item
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-viewInvestigationItem
.... code 1..1 CodeableConcept A name/code for the set
Binding: http://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes (example)
.... item 0..* Reference(ehealth-media | ehealth-observation | ehealth-questionnaireresponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) {r} Record of a specific investigation
... finding
.... itemCodeableConcept 0..1 CodeableConcept What was found
Binding: ClinicalImpression Finding Codes (required)
.... itemReference 0..1 Reference(Observation | ehealth-condition) What was found
... prognosisReference 0..* Reference(RiskAssessment) {r} RiskAssessment expressing likely outcome
... note
.... Slices for author[x] 0..1 Reference(Practitioner | Patient | RelatedPerson | Organization), string Individual responsible for the annotation
Slice: Unordered, Open by type:$this
..... author[x]:authorReference 0..1 Reference(ehealth-practitioner | ehealth-patient | ehealth-relatedperson) Individual responsible for the annotation
..... author[x]:authorString 0..1 string Individual responsible for the annotation

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClinicalImpression.coderequiredClinicalImpressionCodes (a valid code from ClinicalImpression Codes)
http://ehealth.sundhed.dk/vs/clinicalimpression-codes
from this IG
ClinicalImpression.investigation.codeexamplehttp://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes
http://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes
ClinicalImpression.finding.itemCodeableConceptrequiredClinicalImpressionFindingCodes
http://ehealth.sundhed.dk/vs/clinicalimpression-finding-codes
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... assessorOrganization 0..1 Reference(ehealth-organization) {r} Assessors Organization
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-assessor-organization
.... carePlan 0..1 Reference(ehealth-careplan) {r} The Careplan
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-careplan
.... decisionContext 0..* Reference(Parameters) {r, c} Library and relevant resources used for evaluation
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionContext
.... decision 0..* CodeableConcept approved | approved-for-sharing
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decision
Binding: ClinicalImpression Decision Codes (required)
.... episodeOfCare 1..1 Reference(EpisodeOfCare) Associated Encounter episode of care
URL: http://hl7.org/fhir/StructureDefinition/workflow-episodeOfCare
.... findingBasis 0..* (Complex) The basis for a clinical impression finding
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaireresponse-finding-basis
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... code Σ 1..1 CodeableConcept Kind of assessment performed
Binding: Clinical Impression Codes (required)
... subject Σ 1..1 Reference(ehealth-patient) {r} Patient or group assessed
... assessor Σ 0..1 Reference(ehealth-practitioner) {r} The clinician performing the assessment
... previous 0..1 Reference(ehealth-clinicalimpression) {r} Reference to last assessment
... problem Σ 0..* Reference(ehealth-condition | AllergyIntolerance) {r} Relevant impressions of patient state
... prognosisReference 0..* Reference(RiskAssessment) {r} RiskAssessment expressing likely outcome

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClinicalImpression.statusrequiredClinicalImpressionStatus
http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1
from the FHIR Standard
ClinicalImpression.coderequiredClinicalImpressionCodes (a valid code from ClinicalImpression Codes)
http://ehealth.sundhed.dk/vs/clinicalimpression-codes
from this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... assessorOrganization 0..1 Reference(ehealth-organization) {r} Assessors Organization
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-assessor-organization
.... carePlan 0..1 Reference(ehealth-careplan) {r} The Careplan
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-careplan
.... decisionContext 0..* Reference(Parameters) {r, c} Library and relevant resources used for evaluation
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decisionContext
.... decision 0..* CodeableConcept approved | approved-for-sharing
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-decision
Binding: ClinicalImpression Decision Codes (required)
.... episodeOfCare 1..1 Reference(EpisodeOfCare) Associated Encounter episode of care
URL: http://hl7.org/fhir/StructureDefinition/workflow-episodeOfCare
.... findingBasis 0..* (Complex) The basis for a clinical impression finding
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-questionnaireresponse-finding-basis
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier
... status ?!Σ 1..1 code in-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.

... statusReason 0..1 CodeableConcept Reason for current status
Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.

... code Σ 1..1 CodeableConcept Kind of assessment performed
Binding: Clinical Impression Codes (required)
... description Σ 0..1 string Why/how the assessment was performed
... subject Σ 1..1 Reference(ehealth-patient) {r} Patient or group assessed
... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
... effective[x] Σ 0..1 Time of assessment
.... effectiveDateTime dateTime
.... effectivePeriod Period
... date Σ 0..1 dateTime When the assessment was documented
... assessor Σ 0..1 Reference(ehealth-practitioner) {r} The clinician performing the assessment
... previous 0..1 Reference(ehealth-clinicalimpression) {r} Reference to last assessment
... problem Σ 0..* Reference(ehealth-condition | AllergyIntolerance) {r} Relevant impressions of patient state
... investigation 0..* BackboneElement One or more sets of investigations (signs, symptoms, etc.)
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... viewInvestigationItem 0..* Reference(ehealth-view) {r} View item
URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-clinicalimpression-viewInvestigationItem
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code 1..1 CodeableConcept A name/code for the set
Binding: http://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes (example)
.... item 0..* Reference(ehealth-media | ehealth-observation | ehealth-questionnaireresponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) {r} Record of a specific investigation
... protocol 0..* uri Clinical Protocol followed
... summary 0..1 string Summary of the assessment
... finding 0..* BackboneElement Possible or likely findings and diagnoses
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1 CodeableConcept What was found
Binding: ClinicalImpression Finding Codes (required)
.... itemReference 0..1 Reference(Observation | ehealth-condition) What was found
.... basis 0..1 string Which investigations support finding
... prognosisCodeableConcept 0..* CodeableConcept Estimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.


... prognosisReference 0..* Reference(RiskAssessment) {r} RiskAssessment expressing likely outcome
... supportingInfo 0..* Reference(Resource) Information supporting the clinical impression
... note 0..* Annotation Comments made about the ClinicalImpression
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for author[x] Σ 0..1 Individual responsible for the annotation
Slice: Unordered, Closed by type:$this
..... authorReference Reference(Practitioner | Patient | RelatedPerson | Organization)
..... authorString string
..... author[x]:authorReference Σ 0..1 Reference(ehealth-practitioner | ehealth-patient | ehealth-relatedperson) Individual responsible for the annotation
..... author[x]:authorString Σ 0..1 string Individual responsible for the annotation
.... time Σ 0..1 dateTime When the annotation was made
.... text Σ 1..1 markdown The annotation - text content (as markdown)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClinicalImpression.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClinicalImpression.statusrequiredClinicalImpressionStatus
http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1
from the FHIR Standard
ClinicalImpression.statusReasonexample
ClinicalImpression.coderequiredClinicalImpressionCodes (a valid code from ClinicalImpression Codes)
http://ehealth.sundhed.dk/vs/clinicalimpression-codes
from this IG
ClinicalImpression.investigation.codeexamplehttp://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes
http://ehealth.sundhed.dk/vs/clinicalimpression-investigation-item-codes
ClinicalImpression.finding.itemCodeableConceptrequiredClinicalImpressionFindingCodes
http://ehealth.sundhed.dk/vs/clinicalimpression-finding-codes
from this IG
ClinicalImpression.prognosisCodeableConceptexampleClinicalImpressionPrognosis
http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis
from the FHIR Standard

This structure is derived from ClinicalImpression

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of ClinicalImpression.note.author[x]

 

Other representations of profile: CSV, Excel, Schematron