ClinicalImpression - FHIR Resource (r4)
This ClinicalImpression Resource uses the
FHIR API standard for access and structure.
Validate an ClinicalImpression FHIR Resource (r4)
Resource Attributes
Attribute | Field is list | Type | Description |
---|
assessor | false | Reference | # The clinician performing the assessment |
code | false | CodeableConcept | # Kind of assessment performed |
date | false | dateTime | # When the assessment was documented |
description | false | string | # Why/how the assessment was performed |
effective[x] | false | dateTime|Period | #undefined |
encounter | false | Reference | # Encounter created as part of |
finding | true | Data Type | # Possible or likely findings and diagnoses |
identifier | true | Identifier | # Business identifier |
investigation | true | Data Type | # One or more sets of investigations (signs, symptoms, etc.) |
note | true | Annotation | # Comments made about the ClinicalImpression |
previous | false | Reference | # Reference to last assessment |
problem | true | Reference | # Relevant impressions of patient state |
prognosisCodeableConcept | true | CodeableConcept | # Estimate of likely outcome |
prognosisReference | true | Reference | # RiskAssessment expressing likely outcome |
protocol | true | uri | # Clinical Protocol followed |
status | false | code | # in-progress | completed | entered-in-error |
statusReason | false | CodeableConcept | # Reason for current status |
subject | false | Reference | # Patient or group assessed |
summary | false | string | # Summary of the assessment |
supportingInfo | true | Reference | # 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 --> 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 |