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.r4b.core
derivation: specialization
name: ClinicalImpression
type: ClinicalImpression
elements:
  description: {isModifier: false, short: Why/how the assessment was performed, type: string, mustSupport: false, isSummary: true, index: 4}
  date: {isModifier: false, short: When the assessment was documented, type: dateTime, mustSupport: false, isSummary: true, index: 11}
  investigation:
    isModifier: false
    short: One or more sets of investigations (signs, symptoms, etc.)
    index: 15
    type: BackboneElement
    mustSupport: false
    array: true
    elements:
      code:
        isModifier: false
        short: A name/code for the set
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/investigation-sets'}
        isSummary: false
        index: 16
      item:
        isModifier: false
        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
        mustSupport: false
        array: true
        isSummary: false
        index: 17
    required: [code]
    isSummary: false
  protocol: {isModifier: false, short: Clinical Protocol followed, type: uri, mustSupport: false, array: true, isSummary: false, index: 18}
  assessor:
    isModifier: false
    short: The clinician performing the assessment
    refers: ['http://hl7.org/fhir/StructureDefinition/Practitioner', 'http://hl7.org/fhir/StructureDefinition/PractitionerRole']
    type: Reference
    mustSupport: false
    isSummary: true
    index: 12
  supportingInfo:
    isModifier: false
    short: Information supporting the clinical impression
    refers: ['http://hl7.org/fhir/StructureDefinition/Resource']
    type: Reference
    mustSupport: false
    array: true
    isSummary: false
    index: 26
  encounter:
    isModifier: false
    short: Encounter created as part of
    refers: ['http://hl7.org/fhir/StructureDefinition/Encounter']
    type: Reference
    mustSupport: false
    isSummary: true
    index: 6
  problem:
    isModifier: false
    short: Relevant impressions of patient state
    refers: ['http://hl7.org/fhir/StructureDefinition/AllergyIntolerance', 'http://hl7.org/fhir/StructureDefinition/Condition']
    type: Reference
    mustSupport: false
    array: true
    isSummary: true
    index: 14
  statusReason: {isModifier: false, short: Reason for current status, type: CodeableConcept, mustSupport: false, isSummary: false, index: 2}
  note: {isModifier: false, short: Comments made about the ClinicalImpression, type: Annotation, mustSupport: false, array: true, isSummary: false, index: 27}
  summary: {isModifier: false, short: Summary of the assessment, type: string, mustSupport: false, isSummary: false, index: 19}
  effectiveDateTime: {isModifier: false, short: Time of assessment, type: dateTime, mustSupport: false, choiceOf: effective, isSummary: true, index: 9}
  prognosisCodeableConcept:
    isModifier: false
    short: Estimate of likely outcome
    type: CodeableConcept
    mustSupport: false
    array: true
    binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/clinicalimpression-prognosis'}
    isSummary: false
    index: 24
  status:
    isModifier: true
    short: in-progress | completed | entered-in-error
    index: 1
    type: code
    mustSupport: false
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/clinicalimpression-status|4.3.0'}
    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
  effective:
    isModifier: false
    short: Time of assessment
    mustSupport: false
    choices: [effectiveDateTime, effectivePeriod]
    isSummary: true
    index: 8
  previous:
    isModifier: false
    short: Reference to last assessment
    refers: ['http://hl7.org/fhir/StructureDefinition/ClinicalImpression']
    type: Reference
    mustSupport: false
    isSummary: false
    index: 13
  code: {isModifier: false, short: Kind of assessment performed, type: CodeableConcept, mustSupport: false, isSummary: true, index: 3}
  identifier: {isModifier: false, short: Business identifier, type: Identifier, mustSupport: false, array: true, isSummary: true, index: 0}
  finding:
    isModifier: false
    short: Possible or likely findings and diagnoses
    type: BackboneElement
    mustSupport: false
    array: true
    isSummary: false
    index: 20
    elements:
      itemCodeableConcept:
        isModifier: false
        short: What was found
        type: CodeableConcept
        mustSupport: false
        binding: {strength: example, valueSet: 'http://hl7.org/fhir/ValueSet/condition-code'}
        isSummary: false
        index: 21
      itemReference:
        isModifier: false
        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
        mustSupport: false
        isSummary: false
        index: 22
      basis: {isModifier: false, short: Which investigations support finding, type: string, mustSupport: false, isSummary: false, index: 23}
  prognosisReference:
    isModifier: false
    short: RiskAssessment expressing likely outcome
    refers: ['http://hl7.org/fhir/StructureDefinition/RiskAssessment']
    type: Reference
    mustSupport: false
    array: true
    isSummary: false
    index: 25
  subject:
    isModifier: false
    short: Patient or group assessed
    refers: ['http://hl7.org/fhir/StructureDefinition/Group', 'http://hl7.org/fhir/StructureDefinition/Patient']
    type: Reference
    mustSupport: false
    isSummary: true
    index: 5
  effectivePeriod: {isModifier: false, short: Time of assessment, type: Period, mustSupport: false, choiceOf: effective, isSummary: true, index: 10}
package_version: 4.3.0
class: resource
kind: resource
url: http://hl7.org/fhir/StructureDefinition/ClinicalImpression
base: http://hl7.org/fhir/StructureDefinition/DomainResource
version: 4.3.0
required: [status, subject]