Resource type: clinicalimpression

Description

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.

Elements

PathShortDefinitionComments
A clinical assessment performed when planning treatments and management strategies for a patientA 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.
identifierBusiness identifierBusiness identifiers assigned to this clinical impression by the performer or other systems which remain constant as the resource is updated and propagates from server to server.This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
statusdraft | completed | entered-in-errorIdentifies the workflow status of the assessment.This element is labeled as a modifier because the status contains the code entered-in-error that marks the clinical impression as not currently valid.
statusReasonReason for current statusCaptures the reason for the current state of the ClinicalImpression.This is generally only used for "exception" statuses such as "not-done", "suspended" or "cancelled". [distinct reason codes for different statuses can be enforced using invariants if they are universal bindings].
codeKind of assessment performedCategorizes the type of clinical assessment performed.This is present as a place-holder only and may be removed based on feedback/work group opinion.
descriptionWhy/how the assessment was performedA summary of the context and/or cause of the assessment - why / where was it performed, and what patient events/status prompted it.
subjectPatient or group assessedThe patient or group of individuals assessed as part of this record.
encounterEncounter created as part ofThe Encounter during which this ClinicalImpression was created or to which the creation of this record is tightly associated.This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
effective[x]Time of assessmentThe point in time or period over which the subject was assessed.This SHOULD be accurate to at least the minute, though some assessments only have a known date.
dateWhen the assessment was documentedIndicates when the documentation of the assessment was complete.
assessorThe clinician performing the assessmentThe clinician performing the assessment.
previousReference to last assessmentA reference to the last assessment that was conducted on this patient. Assessments are often/usually ongoing in nature; a care provider (practitioner or team) will make new assessments on an ongoing basis as new data arises or the patient's conditions changes.It is always likely that multiple previous assessments exist for a patient. The point of quoting a previous assessment is that this assessment is relative to it (see resolved).
problemRelevant impressions of patient stateThis a list of the relevant problems/conditions for a patient.e.g. The patient is a pregnant, and cardiac congestive failure, ‎Adenocarcinoma, and is allergic to penicillin.
investigationOne or more sets of investigations (signs, symptoms, etc.)One or more sets of investigations (signs, symptoms, etc.). The actual grouping of investigations varies greatly depending on the type and context of the assessment. These investigations may include data generated during the assessment process, or data previously generated and recorded that is pertinent to the outcomes.
investigation.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
investigation.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
investigation.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
investigation.codeA name/code for the setA name/code for the group ("set") of investigations. Typically, this will be something like "signs", "symptoms", "clinical", "diagnostic", but the list is not constrained, and others such groups such as (exposure|family|travel|nutritional) history may be used.
investigation.itemRecord of a specific investigationA record of a specific investigation that was undertaken.Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used.
protocolClinical Protocol followedReference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.
summarySummary of the assessmentA text summary of the investigations and the diagnosis.
findingPossible or likely findings and diagnosesSpecific findings or diagnoses that was considered likely or relevant to ongoing treatment.
finding.idUnique id for inter-element referencingUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
finding.extensionAdditional content defined by implementationsMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
finding.modifierExtensionExtensions that cannot be ignored even if unrecognizedMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
finding.itemCodeableConceptWhat was foundSpecific text or code for finding or diagnosis, which may include ruled-out or resolved conditions.
finding.itemReferenceWhat was foundSpecific reference for finding or diagnosis, which may include ruled-out or resolved conditions.
finding.basisWhich investigations support findingWhich investigations support finding or diagnosis.
prognosisCodeableConceptEstimate of likely outcomeEstimate of likely outcome.
prognosisReferenceRiskAssessment expressing likely outcomeRiskAssessment expressing likely outcome.
supportingInfoInformation supporting the clinical impressionInformation supporting the clinical impression.
noteComments made about the ClinicalImpressionCommentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear.Don't use this element for content that should more properly appear as one of the specific elements of the impression.

Scope and Usage

Performing a clinical assessment is a fundamental part of a clinician's workflow, performed repeatedly throughout the day. In spite of this - or perhaps, because of it - there is wide variance in how clinical impressions are recorded. Some clinical assessments simply result in an impression recorded as a single text note in the patient 'record' (e.g. "Progress satisfactory, continue with treatment"), while others are associated with careful, detailed record keeping of the evidence gathered and the reasoning leading to a differential diagnosis, and there is a continuum between these. This resource is intended to be used to cover all these use cases.

The assessment is intimately linked to the process of care. It may occur in the context of a care plan, and it very often results in a new (or revised) care plan. Normally. clinical assessments are part of an ongoing process of care, and the patient will be re-assessed repeatedly. For this reason, the clinical impression can explicit reference both care plans (preceding and resulting) and reference a previous impression that this impression follows on from.

An impression is a clinical summation of information and/or an opinion formed, which is the outcome of the clinical assessment process. The ClinicalImpression may lead to a statement of a Condition about a patient.

In FHIR, an assessment is typically an instrument or tool used to collect information about a patient.

[%stu-note%] Unlike many other resources, there is little prior art with regard to exchanging records of clinical assessments. For this reason, this resource should be regarded as particularly prone to ongoing revision. In terms of scope and usage, the Patient Care workgroup wishes to draw the attention of reviewers and implementers to the following issues:

Feedback is welcome here. [%end-note%]

Boundaries and Relationships

ClinicalImpression is the equivalent of the "A" in Weed SOAP. It is the outcome of the clinical assessment process. The ClinicalImpression may lead to a statement of a Condition about a patient. There is another related clinical concept often called an "assessment": assessment Tools such as Apgar (also known as "Assessment Scales"). This is not what the ClinicalImpression resource is about; assessment tools such as Apgar are represented as Observations, and Questionnaires may be used to help generate these. Clinical Impressions may refer to these assessment tools as one of the investigations that was performed during the assessment process.

Background and Context

An important background to understanding this resource is the FHIR Confluence page for clinical assessment. In particular, the storyboards there drove the design of the resource, and will be the basis for all examples created.

PLANNED CHANGE:

ClinicalImpression is one of the Event resources in the FHIR Workflow specification. As such, it is expected to be adjusted to align with the Event workflow pattern which will involve adding a number of additional data elements and potentially renaming a few elements. Any concerns about performing such alignment are welcome as ballot comments and/or tracker items.

Known Issue

A known issue exists with circular references between Condition and ClinicalImpression, which is due to the low maturity level of ClinicalImpression. The Patient Care work group intends to address this issue when ClinicalImpression is considered substantially complete and ready for implementation.

Search Parameters

assessorThe clinician performing the assessmentClinicalImpression.assessor
encounterEncounter created as part ofClinicalImpression.encounter
finding-codeWhat was foundClinicalImpression.finding.itemCodeableConcept
finding-refWhat was foundClinicalImpression.finding.itemReference
identifierBusiness identifierClinicalImpression.identifier
investigationRecord of a specific investigationClinicalImpression.investigation.item
previousReference to last assessmentClinicalImpression.previous
problemRelevant impressions of patient stateClinicalImpression.problem
statusdraft | completed | entered-in-errorClinicalImpression.status
subjectPatient or group assessedClinicalImpression.subject
supporting-infoInformation supporting the clinical impressionClinicalImpression.supportingInfo

Extension Definitions

These are extension definitions for this resource defined by the spec