ClinicalImpression - FHIR Resource (r4)


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

Validate an ClinicalImpression FHIR Resource (r4)



Resource Attributes

AttributeField is listTypeDescription
assessorfalseReference# The clinician performing the assessment
codefalseCodeableConcept# Kind of assessment performed
datefalsedateTime# When the assessment was documented
descriptionfalsestring# Why/how the assessment was performed
effective[x]falsedateTime|Period#undefined
encounterfalseReference# Encounter created as part of
findingtrueData Type# Possible or likely findings and diagnoses
identifiertrueIdentifier# Business identifier
investigationtrueData Type# One or more sets of investigations (signs, symptoms, 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# in-progress | completed | entered-in-error
statusReasonfalseCodeableConcept# Reason for current status
subjectfalseReference# Patient or group assessed
summaryfalsestring# Summary of the assessment
supportingInfotrueReference# Information supporting the clinical impression

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 --&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>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 ParameterField TypeResource Fields Searched
assessorreferenceassessor
datedatedate
encounterreferenceencounter
finding-codetextfinding.itemCodeableConcept
finding-refreferencefinding.itemReference
identifiertextidentifier
investigationreferenceinvestigation.item
patientreferencesubject.where
previousreferenceprevious
problemreferenceproblem
statustextstatus
subjectreferencesubject
supporting-inforeferencesupportingInfo