ClinicalImpression - FHIR Resource (r4)
This ClinicalImpression Resource uses the FHIR API standard for access and structure.
Validate an ClinicalImpression FHIR Resource (r4)
ClinicalImpression Attributes
AttributeField is listTypeDescription
Description: Business identifier
FHIR Version: r4
Attribute Type : Identifier
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"identifier": [
{
"value": "12345"
}
]Learn more about the (ClinicalImpression) identifier FHIR attribute
Description: in-progress | completed | entered-in-error
FHIR Version: r4
Attribute Type : code
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"status": "completed"Learn more about the (ClinicalImpression) status FHIR attribute
Description: Reason for current status
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"statusReason": Learn more about the (ClinicalImpression) statusReason FHIR attribute
Description: Kind of assessment performed
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"code": Learn more about the (ClinicalImpression) code FHIR attribute
Description: Why/how the assessment was performed
FHIR Version: r4
Attribute Type : string
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"description": "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident"Learn more about the (ClinicalImpression) description FHIR attribute
Description: Patient or group assessed
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"subject": {
"reference": "Patient/example"
}Learn more about the (ClinicalImpression) subject FHIR attribute
Description: Encounter created as part of
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"encounter": {
"reference": "Encounter/example"
}Learn more about the (ClinicalImpression) encounter FHIR attribute
Description:
FHIR Version: r4
Attribute Type : dateTime|Period
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"effective[x]": Learn more about the (ClinicalImpression) effective[x] FHIR attribute
Description: When the assessment was documented
FHIR Version: r4
Attribute Type : dateTime
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"date": "2014-12-06T22:33:00+11:00"Learn more about the (ClinicalImpression) date FHIR attribute
Description: The clinician performing the assessment
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"assessor": {
"reference": "Practitioner/example"
}Learn more about the (ClinicalImpression) assessor FHIR attribute
Description: Reference to last assessment
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"previous": Learn more about the (ClinicalImpression) previous FHIR attribute
Description: Relevant impressions of patient state
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"problem": [
{
"display": "MVA"
}
]Learn more about the (ClinicalImpression) problem FHIR attribute
Description: One or more sets of investigations (signs, symptoms, etc.)
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"investigation": [
{
"code": {
"text": "Initial Examination"
},
"item": [
{
"display": "deep laceration of the scalp (left temporo-occipital)"
},
{
"display": "decreased level of consciousness"
},
{
"display": "disoriented to time and place"
},
{
"display": "restless"
}
]
}
]Learn more about the (ClinicalImpression) investigation FHIR attribute
Description: Clinical Protocol followed
FHIR Version: r4
Attribute Type : uri
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"protocol": Learn more about the (ClinicalImpression) protocol FHIR attribute
Description: Summary of the assessment
FHIR Version: r4
Attribute Type : string
Required: N/A
Countability: Singleton
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"summary": "provisional diagnoses of laceration of head and traumatic brain injury (TBI)"Learn more about the (ClinicalImpression) summary FHIR attribute
Description: Possible or likely findings and diagnoses
FHIR Version: r4
Attribute Type : Data Type
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"finding": [
{
"itemCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-9",
"code": "850.0"
}
]
}
}
]Learn more about the (ClinicalImpression) finding FHIR attribute
Description: Estimate of likely outcome
FHIR Version: r4
Attribute Type : CodeableConcept
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"prognosisCodeableConcept": Learn more about the (ClinicalImpression) prognosisCodeableConcept FHIR attribute
Description: RiskAssessment expressing likely outcome
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"prognosisReference": Learn more about the (ClinicalImpression) prognosisReference FHIR attribute
Description: Information supporting the clinical impression
FHIR Version: r4
Attribute Type : Reference
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"supportingInfo": Learn more about the (ClinicalImpression) supportingInfo FHIR attribute
Description: Comments made about the ClinicalImpression
FHIR Version: r4
Attribute Type : Annotation
Required: N/A
Countability: Array
Flags: N/A
Terminology bindings: N/A
Requirements: N/A
Comments: N/A
Example:
"note": Learn more about the (ClinicalImpression) note FHIR attribute
ClinicalImpression Example
{
"resourceType": "ClinicalImpression",
"id": "example",
"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>encounter</b>: <a>Encounter/example</a></p><p><b>effective</b>: 06/12/2014 8:00:00 PM --> 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>ItemCodeableConcept</b></td></tr><tr><td>*</td><td>850.0 <span>(Details : {ICD-9 code '850.0' = '850.0)</span></td></tr></table></div>"
},
"identifier": [
{
"value": "12345"
}
],
"status": "completed",
"description": "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident",
"subject": {
"reference": "Patient/example"
},
"encounter": {
"reference": "Encounter/example"
},
"effectivePeriod": {
"start": "2014-12-06T20:00:00+11:00",
"end": "2014-12-06T22:33:00+11:00"
},
"date": "2014-12-06T22:33:00+11:00",
"assessor": {
"reference": "Practitioner/example"
},
"problem": [
{
"display": "MVA"
}
],
"investigation": [
{
"code": {
"text": "Initial Examination"
},
"item": [
{
"display": "deep laceration of the scalp (left temporo-occipital)"
},
{
"display": "decreased level of consciousness"
},
{
"display": "disoriented to time and place"
},
{
"display": "restless"
}
]
}
],
"summary": "provisional diagnoses of laceration of head and traumatic brain injury (TBI)",
"finding": [
{
"itemCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-9",
"code": "850.0"
}
]
}
}
]
}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! in-progress | completed | entered-in-error
"statusReason" : { CodeableConcept }, // Reason for current status
"code" : { CodeableConcept }, // Kind of assessment performed
"description" : "<string>", // Why/how the assessment was performed
"subject" : { Reference(Patient|Group) }, // R! Patient or group assessed
"encounter" : { Reference(Encounter) }, // Encounter created as part of
// effective[x]: Time of assessment. One of these 2:
"effectiveDateTime" : "<dateTime>",
"effectivePeriod" : { Period },
"date" : "<dateTime>", // When the assessment was documented
"assessor" : { Reference(Practitioner|PractitionerRole) }, // 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, symptoms, etc.)
"code" : { CodeableConcept }, // R! A name/code for the set
"item" : [{ Reference(Observation|QuestionnaireResponse|FamilyMemberHistory|
DiagnosticReport|RiskAssessment|ImagingStudy|Media) }] // Record of a specific investigation
}],
"protocol" : ["<uri>"], // Clinical Protocol followed
"summary" : "<string>", // Summary of the assessment
"finding" : [{ // Possible or likely findings and diagnoses
"itemCodeableConcept" : { CodeableConcept }, // What was found
"itemReference" : { Reference(Condition|Observation|Media) }, // What was found
"basis" : "<string>" // Which investigations support finding
}],
"prognosisCodeableConcept" : [{ CodeableConcept }], // Estimate of likely outcome
"prognosisReference" : [{ Reference(RiskAssessment) }], // RiskAssessment expressing likely outcome
"supportingInfo" : [{ Reference(Any) }], // Information supporting the clinical impression
"note" : [{ Annotation }] // Comments made about the ClinicalImpression
}
ClinicalImpression Search Parameters
The following search parameters can be used to query ClinicalImpression resources. Just submit them like so:
https://api.1up.health/fhir/r4/ClinicalImpression?query-param=queryvalue| Search Parameter | Field Type | Resource Fields Searched |
|---|---|---|
assessor | reference | assessor |
date | date | date |
encounter | reference | encounter |
finding-code | text | finding.itemCodeableConcept |
finding-ref | reference | finding.itemReference |
identifier | text | identifier |
investigation | reference | investigation.item |
patient | reference | subject.where |
previous | reference | previous |
problem | reference | problem |
status | text | status |
subject | reference | subject |
supporting-info | reference | supportingInfo |
