ClinicalImpression - FHIR Resource (stu3)
This ClinicalImpression Resource uses the
FHIR API standard for access and structure.
Validate an ClinicalImpression FHIR Resource (stu3)
Resource Attributes
Attribute | Field is list | Type | Description |
---|
action | true | Reference | # "action" : [{ Reference(ReferralRequest|ProcedureRequest|Procedure|
|
assessor | false | Reference | # The clinician performing the assessment
|
code | false | CodeableConcept | # Kind of assessment performed
|
context | false | Reference | # Encounter or Episode created from
|
date | false | dateTime | # When the assessment was documented
|
description | false | string | # Why/how the assessment was performed
|
effectiveDateTime | false | dateTime | # "effectiveDateTime" : "<dateTime>",
|
effectivePeriod | false | Period | # "effectivePeriod" : { Period },
|
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, symptions, 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 | # draft | completed | entered-in-error
|
subject | false | Reference | # Patient or group assessed
|
summary | false | string | # 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 --> 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 them like so:
https://api.1up.health/fhir/stu3/ClinicalImpression?query-param=queryvalue
Search Parameter | Field Type | Resource Fields Searched |
---|
action | reference | action |
assessor | reference | assessor |
context | reference | context |
date | date | date |
finding-code | text | finding.item.as |
finding-ref | reference | finding.item.as |
identifier | text | identifier |
investigation | reference | investigation.item |
patient | reference | subject |
previous | reference | previous |
problem | reference | problem |
status | text | status |
subject | reference | subject |