ClinicalImpression - FHIR Resource (r4)

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

Validate an ClinicalImpression FHIR Resource (r4)

Validate this ClinicalImpression

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 --&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 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