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.
package_name: hl7.fhir.r4.core
derivation: specialization
name: ClinicalImpression
type: ClinicalImpression
elements:
  description: {type: string, short: Why/how the assessment was performed, isSummary: true, index: 4}
  date: {short: When the assessment was documented, type: dateTime, isSummary: true, index: 11}
  investigation:
    type: BackboneElement
    short: One or more sets of investigations (signs, symptoms, etc.)
    array: true
    index: 15
    elements:
      code:
        type: CodeableConcept
        short: A name/code for the set
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/investigation-sets'}
        index: 16
      item:
        short: Record of a specific investigation
        refers: ['http://hl7.org/fhir/StructureDefinition/DiagnosticReport', 'http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory', 'http://hl7.org/fhir/StructureDefinition/ImagingStudy', 'http://hl7.org/fhir/StructureDefinition/Media', 'http://hl7.org/fhir/StructureDefinition/Observation', 'http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse', 'http://hl7.org/fhir/StructureDefinition/RiskAssessment']
        type: Reference
        array: true
        index: 17
    required: [code]
  protocol: {type: uri, short: Clinical Protocol followed, array: true, index: 18}
  assessor:
    short: The clinician performing the assessment
    refers: ['http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    isSummary: true
    index: 12
  supportingInfo:
    type: Reference
    short: Information supporting the clinical impression
    refers: ['http://hl7.org/fhir/StructureDefinition/Resource']
    array: true
    index: 26
  encounter:
    short: Encounter created as part of
    refers: ['http://hl7.org/fhir/StructureDefinition/Encounter']
    type: Reference
    isSummary: true
    index: 6
  problem:
    short: Relevant impressions of patient state
    refers: ['http://hl7.org/fhir/StructureDefinition/AllergyIntolerance', 'http://hl7.org/fhir/StructureDefinition/Condition']
    type: Reference
    array: true
    isSummary: true
    index: 14
  statusReason: {short: Reason for current status, type: CodeableConcept, index: 2}
  note: {short: Comments made about the ClinicalImpression, type: Annotation, array: true, index: 27}
  summary: {type: string, short: Summary of the assessment, index: 19}
  effectiveDateTime: {short: Time of assessment, type: dateTime, choiceOf: effective, isSummary: true, index: 9}
  prognosisCodeableConcept:
    short: Estimate of likely outcome
    type: CodeableConcept
    array: true
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis'}
    index: 24
  status:
    isModifier: true
    short: in-progress | completed | entered-in-error
    type: code
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.0.1'}
    isModifierReason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    isSummary: true
    index: 1
  effective:
    short: Time of assessment
    choices: [effectiveDateTime, effectivePeriod]
    isSummary: true
    index: 8
  previous:
    short: Reference to last assessment
    refers: ['http://hl7.org/fhir/StructureDefinition/ClinicalImpression']
    type: Reference
    index: 13
  code: {short: Kind of assessment performed, type: CodeableConcept, isSummary: true, index: 3}
  identifier: {short: Business identifier, type: Identifier, array: true, isSummary: true, index: 0}
  finding:
    type: BackboneElement
    short: Possible or likely findings and diagnoses
    array: true
    index: 20
    elements:
      itemCodeableConcept:
        short: What was found
        type: CodeableConcept
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/condition-code'}
        index: 21
      itemReference:
        short: What was found
        refers: ['http://hl7.org/fhir/StructureDefinition/Condition', 'http://hl7.org/fhir/StructureDefinition/Media', 'http://hl7.org/fhir/StructureDefinition/Observation']
        type: Reference
        index: 22
      basis: {type: string, short: Which investigations support finding, index: 23}
  prognosisReference:
    type: Reference
    short: RiskAssessment expressing likely outcome
    refers: ['http://hl7.org/fhir/StructureDefinition/RiskAssessment']
    array: true
    index: 25
  subject:
    short: Patient or group assessed
    refers: ['http://hl7.org/fhir/StructureDefinition/Group', 'http://hl7.org/fhir/StructureDefinition/Patient']
    type: Reference
    isSummary: true
    index: 5
  effectivePeriod: {short: Time of assessment, type: Period, choiceOf: effective, isSummary: true, index: 10}
package_version: 4.0.1
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ClinicalImpression
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 4.0.1
required: [status, subject]