ClinicalImpression - FHIR Resource (stu3)


This ClinicalImpression Resource uses the FHIR API standard for access and structure.

Validate an ClinicalImpression FHIR Resource (stu3)



Resource Attributes

AttributeField is listTypeDescription
actiontrueReference "action" : [{ Reference(ReferralRequest|ProcedureRequest|Procedure|
assessorfalseReference The clinician performing the assessment
codefalseCodeableConcept Kind of assessment performed
contextfalseReference Encounter or Episode created from
datefalsedateTime When the assessment was documented
descriptionfalsestring Why/how the assessment was performed
effectiveDateTimefalsedateTime "effectiveDateTime" : "<dateTime>",
effectivePeriodfalsePeriod "effectivePeriod" : { Period },
findingtrueData Type Possible or likely findings and diagnoses
identifiertrueIdentifier Business identifier
investigationtrueData Type One or more sets of investigations (signs, symptions, etc.)
notetrueAnnotation Comments made about the ClinicalImpression
previousfalseReference Reference to last assessment
problemtrueReference Relevant impressions of patient state
prognosisCodeableConcepttrueCodeableConcept Estimate of likely outcome
prognosisReferencetrueReference RiskAssessment expressing likely outcome
protocoltrueuri Clinical Protocol followed
statusfalsecode draft | completed | entered-in-error
subjectfalseReference Patient or group assessed
summaryfalsestring Summary of the assessment

ClinicalImpression Example

{
  "status": "completed",
  "description": "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident",
  "resourceType": "ClinicalImpression",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: example</p><p><b>identifier</b>: 12345</p><p><b>status</b>: completed</p><p><b>description</b>: This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident</p><p><b>subject</b>: <a>Patient/example</a></p><p><b>context</b>: <a>Encounter/example</a></p><p><b>effective</b>: 06/12/2014 8:00:00 PM --&gt; 06/12/2014 10:33:00 PM</p><p><b>date</b>: 06/12/2014 10:33:00 PM</p><p><b>assessor</b>: <a>Practitioner/example</a></p><p><b>problem</b>: MVA</p><h3>Investigations</h3><table><tr><td>-</td><td><b>Code</b></td><td><b>Item</b></td></tr><tr><td>*</td><td>Initial Examination <span>(Details )</span></td><td>deep laceration of the scalp (left temporo-occipital)</td></tr></table><p><b>summary</b>: provisional diagnoses of laceration of head and traumatic brain injury (TBI)</p><h3>Findings</h3><table><tr><td>-</td><td><b>Item[x]</b></td></tr><tr><td>*</td><td>850.0 <span>(Details : {ICD-9 code '850.0' = '850.0)</span></td></tr></table></div>"
  },
  "effectivePeriod": {
    "start": "2014-12-06T20:00:00+11:00",
    "end": "2014-12-06T22:33:00+11:00"
  },
  "assessor": {
    "reference": "Practitioner/example"
  },
  "finding": [
    {
      "itemCodeableConcept": {
        "coding": [
          {
            "code": "850.0",
            "system": "http://hl7.org/fhir/sid/icd-9"
          }
        ]
      }
    }
  ],
  "investigation": [
    {
      "item": [
        {
          "display": "deep laceration of the scalp (left temporo-occipital)"
        },
        {
          "display": "decreased level of consciousness"
        },
        {
          "display": "disoriented to time and place"
        },
        {
          "display": "restless"
        }
      ],
      "code": {
        "text": "Initial Examination"
      }
    }
  ],
  "summary": "provisional diagnoses of laceration of head and traumatic brain injury (TBI)",
  "context": {
    "reference": "Encounter/example"
  },
  "date": "2014-12-06T22:33:00+11:00",
  "problem": [
    {
      "display": "MVA"
    }
  ],
  "identifier": [
    {
      "value": "12345"
    }
  ],
  "id": "example",
  "subject": {
    "reference": "Patient/example"
  }
}

ClinicalImpression Structure


  
{
  "resourceType" : "ClinicalImpression",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business identifier
  "status" : "<code>", // R!  draft | completed | entered-in-error
  "code" : { CodeableConcept }, // Kind of assessment performed
  "description" : "<string>", // Why/how the assessment was performed
  "subject" : { Reference(Patient|Group) }, // R!  Patient or group assessed
  "context" : { Reference(Encounter|EpisodeOfCare) }, // Encounter or Episode created from
  // effective[x]: Time of assessment. One of these 2:
  "effectiveDateTime" : "<dateTime>",
  "effectivePeriod" : { Period },
  "date" : "<dateTime>", // When the assessment was documented
  "assessor" : { Reference(Practitioner) }, // The clinician performing the assessment
  "previous" : { Reference(ClinicalImpression) }, // Reference to last assessment
  "problem" : [{ Reference(Condition|AllergyIntolerance) }], // Relevant impressions of patient state
  "investigation" : [{ // One or more sets of investigations (signs, symptions, etc.)
    "code" : { CodeableConcept }, // R!  A name/code for the set
    "item" : [{ Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|
    DiagnosticReport|RiskAssessment|ImagingStudy) }] // Record of a specific investigation
  }],
  "protocol" : ["<uri>"], // Clinical Protocol followed
  "summary" : "<string>", // Summary of the assessment
  "finding" : [{ // Possible or likely findings and diagnoses
    // item[x]: What was found. One of these 2:
    "itemCodeableConcept" : { CodeableConcept },
    "itemReference" : { Reference(Condition|Observation) },
    "basis" : "<string>" // Which investigations support finding
  }],
  "prognosisCodeableConcept" : [{ CodeableConcept }], // Estimate of likely outcome
  "prognosisReference" : [{ Reference(RiskAssessment) }], // RiskAssessment expressing likely outcome
  "action" : [{ Reference(ReferralRequest|ProcedureRequest|Procedure|
   MedicationRequest|Appointment) }], // Action taken as part of assessment procedure
  "note" : [{ Annotation }] // Comments made about the ClinicalImpression
}


 

ClinicalImpression Search Parameters

The following search parameters can be used to query ClinicalImpression resources. Just submit the like so:

https://api.1up.health/fhir/stu3/ClinicalImpression?query-param=queryvalue
Search ParameterField TypeResource Fields Searched
actionreferenceaction
assessorreferenceassessor
contextreferencecontext
datedatedate
finding-codetextfinding.item.as
finding-refreferencefinding.item.as
identifiertextidentifier
investigationreferenceinvestigation.item
patientreferencesubject
previousreferenceprevious
problemreferenceproblem
statustextstatus
subjectreferencesubject