description: Base StructureDefinition for ClinicalImpression Resource
package_name: hl7.fhir.core
derivation: specialization
name: ClinicalImpression
type: ClinicalImpression
elements:
  description: {type: string, short: Why/how the assessment was performed, isSummary: true, index: 3}
  date: {short: When the assessment was documented, type: dateTime, isSummary: true, index: 6}
  investigation:
    type: BackboneElement
    short: One or more sets of investigations (signs, symptions, etc.)
    array: true
    index: 14
    elements:
      code: {type: CodeableConcept, short: A name/code for the set, index: 15}
      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/Observation', 'http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse', 'http://hl7.org/fhir/StructureDefinition/RiskAssessment']
        comments: Most investigations are observations of one kind of or another but some other specific types of data collection resources can also be used.
        type: Reference
        array: true
        index: 16
    required: [code]
  protocol: {type: uri, short: Clinical Protocol followed, array: true, index: 17}
  assessor:
    short: The clinician performing the assessment
    refers: ['http://hl7.org/fhir/StructureDefinition/Practitioner']
    type: Reference
    isSummary: true
    index: 5
  problem:
    short: Relevant impressions of patient state
    refers: ['http://hl7.org/fhir/StructureDefinition/AllergyIntolerance', 'http://hl7.org/fhir/StructureDefinition/Condition']
    comments: e.g. The patient is a pregnant, and cardiac congestive failure, ‎Adenocarcinoma, and is allergic to penicillin.
    type: Reference
    array: true
    isSummary: true
    index: 13
  note: {type: Annotation, short: Comments made about the ClinicalImpression, comments: Don't use this element for content that should more properly appear as one of the specific elements of the impression., array: true, index: 29}
  summary: {type: string, short: Summary of the assessment, index: 18}
  effectiveDateTime: {short: Time of assessment, comments: 'This SHOULD be accurate to at least the minute, though some assessments only have a known date.', type: dateTime, choiceOf: effective, isSummary: true, index: 9}
  prognosisCodeableConcept: {short: Estimate of likely outcome, type: CodeableConcept, array: true, index: 26}
  status: {isModifier: true, short: draft | completed | entered-in-error, type: code, isSummary: true, index: 1}
  effective:
    short: Time of assessment
    comments: This SHOULD be accurate to at least the minute, though some assessments only have a known date.
    choices: [effectiveDateTime, effectivePeriod]
    isSummary: true
    index: 8
  previous:
    short: Reference to last assessment
    refers: ['http://hl7.org/fhir/StructureDefinition/ClinicalImpression']
    comments: 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).
    type: Reference
    index: 12
  code: {short: Kind of assessment performed, comments: This is present as a place-holder only and may be removed based on feedback/work group opinion., type: CodeableConcept, isSummary: true, index: 2}
  identifier: {short: Business identifier, type: Identifier, array: true, isSummary: true, index: 0}
  context:
    short: Encounter or Episode created from
    refers: ['http://hl7.org/fhir/StructureDefinition/Encounter', 'http://hl7.org/fhir/StructureDefinition/EpisodeOfCare']
    type: Reference
    isSummary: true
    index: 11
  action:
    short: Action taken as part of assessment procedure
    refers: ['http://hl7.org/fhir/StructureDefinition/Appointment', 'http://hl7.org/fhir/StructureDefinition/DiagnosticRequest', 'http://hl7.org/fhir/StructureDefinition/MedicationRequest', 'http://hl7.org/fhir/StructureDefinition/Procedure', 'http://hl7.org/fhir/StructureDefinition/ProcedureRequest', 'http://hl7.org/fhir/StructureDefinition/ReferralRequest']
    comments: Actions recommended as a result of the impression should not be captured using the 'action' element.
    type: Reference
    array: true
    index: 28
  finding:
    type: BackboneElement
    short: Possible or likely findings and diagnoses
    array: true
    index: 19
    elements:
      item:
        short: What was found
        choices: [itemCodeableConcept, itemReference, itemReference]
        index: 21
      itemCodeableConcept: {short: What was found, type: CodeableConcept, choiceOf: item, index: 22}
      itemReference:
        short: What was found
        refers: ['http://hl7.org/fhir/StructureDefinition/Condition']
        type: Reference
        choiceOf: item
        index: 23
      basis: {type: string, short: Which investigations support finding, index: 25}
    required: [itemReference, item, itemCodeableConcept]
  prognosisReference:
    type: Reference
    short: RiskAssessment expressing likely outcome
    refers: ['http://hl7.org/fhir/StructureDefinition/RiskAssessment']
    array: true
    index: 27
  subject:
    short: Patient or group assessed
    refers: ['http://hl7.org/fhir/StructureDefinition/Group', 'http://hl7.org/fhir/StructureDefinition/Patient']
    type: Reference
    isSummary: true
    index: 4
  effectivePeriod: {short: Time of assessment, comments: 'This SHOULD be accurate to at least the minute, though some assessments only have a known date.', type: Period, choiceOf: effective, isSummary: true, index: 10}
package_version: 1.8.0
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ClinicalImpression
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: null
required: [status, subject]