ClinicalImpression

A record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition. Assessments are often 1:1 with a clinical consultation / encounter, but this varies greatly depending on the clinical workflow. This resource is called "ClinicalImpression" rather than "ClinicalAssessment" to avoid confusion with the recording of assessment tools such as Apgar score.

Schema

Elements

Name	Required	Type	Description
identifier		Identifier[]	Business identifier Details Business identifiers assigned to this clinical impression by the performer or other systems which remain constant as the resource is updated and propagates from server to server. This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
status	✓	code	in-progress | completed | entered-in-error Details Identifies the workflow status of the assessment. This element is labeled as a modifier because the status contains the code entered-in-error that marks the clinical impression as not currently valid.
statusReason		CodeableConcept	Reason for current status Details Captures the reason for the current state of the ClinicalImpression. This is generally only used for "exception" statuses such as "not-done", "suspended" or "cancelled". [distinct reason codes for different statuses can be enforced using invariants if they are universal bindings].
code		CodeableConcept	Kind of assessment performed Details Categorizes the type of clinical assessment performed. This is present as a place-holder only and may be removed based on feedback/work group opinion.
description		string	Why/how the assessment was performed Details A summary of the context and/or cause of the assessment - why / where it was performed, and what patient events/status prompted it.
subject	✓	Reference<Patient | Group>	Patient or group assessed Details The patient or group of individuals assessed as part of this record.
encounter		Reference<Encounter>	Encounter created as part of Details The Encounter during which this ClinicalImpression was created or to which the creation of this record is tightly associated. This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
effective[x]		dateTime, Period	Time of assessment Details The point in time or period over which the subject was assessed. This SHOULD be accurate to at least the minute, though some assessments only have a known date.
date		dateTime	When the assessment was documented Details Indicates when the documentation of the assessment was complete.
assessor		Reference<Practitioner | PractitionerRole>	The clinician performing the assessment Details The clinician performing the assessment.
previous		Reference<ClinicalImpression>	Reference to last assessment Details A reference to the last assessment that was conducted on this patient. Assessments are often/usually ongoing in nature; a care provider (practitioner or team) will make new assessments on an ongoing basis as new data arises or the patient's conditions changes. It is always likely that multiple previous assessments exist for a patient. The point of quoting a previous assessment is that this assessment is relative to it (see resolved).
problem		Reference<Condition | AllergyIntolerance>[]	Relevant impressions of patient state Details A list of the relevant problems/conditions for a patient. e.g. The patient is a pregnant, has congestive heart failure, has an ‎Adenocarcinoma, and is allergic to penicillin.
investigation		ClinicalImpressionInvestigation[]	One or more sets of investigations (signs, symptoms, etc.) Details One or more sets of investigations (signs, symptoms, etc.). The actual grouping of investigations varies greatly depending on the type and context of the assessment. These investigations may include data generated during the assessment process, or data previously generated and recorded that is pertinent to the outcomes.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
code	✓	CodeableConcept	A name/code for the set Details A name/code for the group ("set") of investigations. Typically, this will be something like "signs", "symptoms", "clinical", "diagnostic", but the list is not constrained, and others such groups such as (exposure|family|travel|nutritional) history may be used.
item		Reference< Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media >[]	Record of a specific investigation Details A record of a specific investigation that was undertaken. Most investigations are observations of one kind or another but some other specific types of data collection resources can also be used.
protocol		uri[]	Clinical Protocol followed Details Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.
summary		string	Summary of the assessment Details A text summary of the investigations and the diagnosis.
finding		ClinicalImpressionFinding[]	Possible or likely findings and diagnoses Details Specific findings or diagnoses that were considered likely or relevant to ongoing treatment.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
itemCodeableConcept		CodeableConcept	What was found Details Specific text or code for finding or diagnosis, which may include ruled-out or resolved conditions.
itemReference		Reference< Condition | Observation | Media >	What was found Details Specific reference for finding or diagnosis, which may include ruled-out or resolved conditions.
basis		string	Which investigations support finding Details Which investigations support finding or diagnosis.
prognosisCodeableConcept		CodeableConcept[]	Estimate of likely outcome Details Estimate of likely outcome.
prognosisReference		Reference<RiskAssessment>[]	RiskAssessment expressing likely outcome Details RiskAssessment expressing likely outcome.
supportingInfo		Reference<Resource>[]	Information supporting the clinical impression Details Information supporting the clinical impression.
note		Annotation[]	Comments made about the ClinicalImpression Details Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear. Don't use this element for content that should more properly appear as one of the specific elements of the impression.

Search Parameters

Name	Type	Description	Expression
date	date	When the assessment was documented	ClinicalImpression.date
patient	reference	Patient or group assessed	ClinicalImpression.subject.where(resolve() is Patient)
assessor	reference	The clinician performing the assessment	ClinicalImpression.assessor
encounter	reference	Encounter created as part of	ClinicalImpression.encounter
finding-code	token	What was found	ClinicalImpression.finding.itemCodeableConcept
finding-ref	reference	What was found	ClinicalImpression.finding.itemReference
identifier	token	Business identifier	ClinicalImpression.identifier
investigation	reference	Record of a specific investigation	ClinicalImpression.investigation.item
previous	reference	Reference to last assessment	ClinicalImpression.previous
problem	reference	Relevant impressions of patient state	ClinicalImpression.problem
status	token	in-progress | completed | entered-in-error	ClinicalImpression.status
subject	reference	Patient or group assessed	ClinicalImpression.subject
supporting-info	reference	Information supporting the clinical impression	ClinicalImpression.supportingInfo

Inherited Elements

Name	Required	Type	Description
id		string	Logical id of this artifact Details The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
meta		Meta	Metadata about the resource Details The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRules		uri	A set of rules under which this content was created Details A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
language		code	Language of the resource content Details The base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
text		Narrative	Text summary of the resource, for human interpretation Details A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
contained		Resource[]	Contained, inline Resources Details These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored Details May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Usage

Performing a clinical assessment is a fundamental part of a clinician's workflow, performed repeatedly throughout the day. In spite of this - or perhaps, because of it - there is wide variance in how clinical impressions are recorded. Some clinical assessments simply result in an impression recorded as a single text note in the patient 'record' (e.g. "Progress satisfactory, continue with treatment"), while others are associated with careful, detailed record keeping of the evidence gathered and the reasoning leading to a differential diagnosis, and there is a continuum between these. This resource is intended to be used to cover all these use cases.

The assessment is intimately linked to the process of care. It may occur in the context of a care plan, and it very often results in a new (or revised) care plan. Normally, clinical assessments are part of an ongoing process of care, and the patient will be re-assessed repeatedly. For this reason, the clinical impression can explicitly reference both care plans (preceding and resulting) and reference a previous impression that this impression follows.

An impression is a clinical summation of information and/or an opinion formed, which is the outcome of the clinical assessment process. The ClinicalImpression may lead to a statement of a Condition about a patient.

In FHIR, an assessment is typically an instrument or tool used to collect information about a patient.

Trial-Use Note: Unlike many other resources, there is little prior art with regard to exchanging records of clinical assessments. For this reason, this resource should be regarded as particularly prone to ongoing revision. In terms of scope and usage, the Patient Care workgroup wishes to draw the attention of reviewers and implementers to the following issues:

• When is an existing clinical impression revised, rather than a new one created (that references the existing one)? How does that affect the status? what's the interplay between the status of the diagnosis and the status of the impression? (e.g. for a 'provisional' impression, which bit is provisional?)
• This structure doesn't differentiate between a working and a final diagnosis. Given an answer to the previous question, should it?
• Further clarify around the relationship between care plan and impression is needed. Both answers to the previous questions and ongoing discussions around revisions to the care plan will influence the design of clinical impression
• Should prognosis be represented, and if so, how much structure should it have?
• Should an impression reference other impressions that are related? (how related?)
• Investigations - the specification needs a good value set for the code for the group, and will be considering the name "investigations" further

Feedback is welcome here .

Relationships

ClinicalImpression is the equivalent of the "A" in Weed SOAP. It is the outcome of the clinical assessment process. The ClinicalImpression may lead to a statement of a Condition about a patient. There is another related clinical concept often called an "assessment": assessment Tools such as Apgar (also known as "Assessment Scales"). This is not what the ClinicalImpression resource is about; assessment tools such as Apgar are represented as Observations, and Questionnaires may be used to help generate these. Clinical Impressions may refer to these assessment tools as one of the investigations that was performed during the assessment process.

Background and Context

An important background to understanding this resource is the FHIR Confluence page for clinical assessment . In particular, the storyboards there drove the design of the resource, and will be the basis for all examples created.

PLANNED CHANGE:

ClinicalImpression is one of the Event resources in the FHIR Workflow specification. As such, it is expected to be adjusted to align with the Event workflow pattern which will involve adding a number of additional data elements and potentially renaming a few elements. Any concerns about performing such alignment are welcome as ballot comments and/or tracker items.

Referenced By

• Condition