FHIR Release 3 (STU)
Clinical SummaryThis page is part of the FHIR Specification (v3.0.2: STU 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
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| Patient Care Work Group | Maturity Level: 0 | Draft | Compartments: Encounter, Patient, Practitioner |
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.
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 explicit reference both care plans (preceeding and resulting) and reference a previous impression that this impression follows on from.
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.
STU 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
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.
An important background to understanding this resource is the FHIR wiki 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.
This resource is referenced by condition
Structure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClinicalImpression | DomainResource | A clinical assessment performed when planning treatments and management strategies for a patient Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | ||
  identifier | Σ | 0..* | Identifier | Business identifier |
 status | ?!Σ | 1..1 | code | draft | completed | entered-in-error ClinicalImpressionStatus (Required) |
| code | Σ | 0..1 | CodeableConcept | Kind of assessment performed |
| description | Σ | 0..1 | string | Why/how the assessment was performed |
 subject | Σ | 1..1 | Reference(Patient | Group) | Patient or group assessed |
| context | Σ | 0..1 | Reference(Encounter | EpisodeOfCare) | Encounter or Episode created from |
 effective[x] | Σ | 0..1 | Time of assessment | |
 effectiveDateTime | dateTime | |||
 effectivePeriod | Period | |||
| date | Σ | 0..1 | dateTime | When the assessment was documented |
| assessor | Σ | 0..1 | Reference(Practitioner) | The clinician performing the assessment |
| previous | 0..1 | Reference(ClinicalImpression) | Reference to last assessment | |
| problem | Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state |
 investigation | 0..* | BackboneElement | One or more sets of investigations (signs, symptions, etc.) | |
| code | 1..1 | CodeableConcept | A name/code for the set Investigation Type (Example) | |
| item | 0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) | Record of a specific investigation | |
| protocol | 0..* | uri | Clinical Protocol followed | |
| summary | 0..1 | string | Summary of the assessment | |
| finding | 0..* | BackboneElement | Possible or likely findings and diagnoses | |
| item[x] | 1..1 | What was found Condition/Problem/Diagnosis Codes (Example) | ||
| itemCodeableConcept | CodeableConcept | |||
| itemReference | Reference(Condition | Observation) | |||
| basis | 0..1 | string | Which investigations support finding | |
| prognosisCodeableConcept | 0..* | CodeableConcept | Estimate of likely outcome Clinical Impression Prognosis (Example) | |
| prognosisReference | 0..* | Reference(RiskAssessment) | RiskAssessment expressing likely outcome | |
| action | 0..* | Reference(ReferralRequest | ProcedureRequest | Procedure | MedicationRequest | Appointment) | Action taken as part of assessment procedure | |
| note | 0..* | Annotation | Comments made about the ClinicalImpression | |
| Documentation for this format |
UML Diagram (Legend)
XML Template
<ClinicalImpression xmlns="http://hl7.org/fhir"><!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business identifier --></identifier> <status value="[code]"/><!-- 1..1 draft | completed | entered-in-error --> <code><!-- 0..1 CodeableConcept Kind of assessment performed --></code> <description value="[string]"/><!-- 0..1 Why/how the assessment was performed --> <subject><!-- 1..1 Reference(Patient|Group) Patient or group assessed --></subject> <context><!-- 0..1 Reference(Encounter|EpisodeOfCare) Encounter or Episode created from --></context> <effective[x]><!-- 0..1 dateTime|Period Time of assessment --></effective[x]> <date value="[dateTime]"/><!-- 0..1 When the assessment was documented --> <assessor><!-- 0..1 Reference(Practitioner) The clinician performing the assessment --></assessor> <previous><!-- 0..1 Reference(ClinicalImpression) Reference to last assessment --></previous> <problem><!-- 0..* Reference(Condition|AllergyIntolerance) Relevant impressions of patient state --></problem> <investigation> <!-- 0..* One or more sets of investigations (signs, symptions, etc.) --> <code><!-- 1..1 CodeableConcept A name/code for the set --></code> <item><!-- 0..* Reference(Observation|QuestionnaireResponse|FamilyMemberHistory| DiagnosticReport|RiskAssessment|ImagingStudy) Record of a specific investigation --></item> </investigation> <protocol value="[uri]"/><!-- 0..* Clinical Protocol followed --> <summary value="[string]"/><!-- 0..1 Summary of the assessment --> <finding> <!-- 0..* Possible or likely findings and diagnoses --> <item[x]><!-- 1..1 CodeableConcept|Reference(Condition|Observation) What was found --></item[x]> <basis value="[string]"/><!-- 0..1 Which investigations support finding --> </finding> <prognosisCodeableConcept><!-- 0..* CodeableConcept Estimate of likely outcome --></prognosisCodeableConcept> <prognosisReference><!-- 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome --></prognosisReference> <action><!-- 0..* Reference(ReferralRequest|ProcedureRequest|Procedure| MedicationRequest|Appointment) Action taken as part of assessment procedure --></action> <note><!-- 0..* Annotation Comments made about the ClinicalImpression --></note> </ClinicalImpression>
JSON Template
{
"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
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .
Changes since DSTU2
| ClinicalImpression | |
| ClinicalImpression.identifier |
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| ClinicalImpression.code |
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| ClinicalImpression.subject |
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| ClinicalImpression.context |
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| ClinicalImpression.effective[x] |
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| ClinicalImpression.investigation |
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| ClinicalImpression.investigation.code |
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| ClinicalImpression.investigation.item |
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| ClinicalImpression.protocol |
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| ClinicalImpression.finding.item[x] |
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| ClinicalImpression.finding.basis |
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| ClinicalImpression.prognosisCodeableConcept |
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| ClinicalImpression.prognosisReference |
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| ClinicalImpression.action |
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| ClinicalImpression.note |
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| ClinicalImpression.trigger[x] |
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| ClinicalImpression.investigations |
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| ClinicalImpression.finding.cause |
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| ClinicalImpression.resolved |
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| ClinicalImpression.ruledOut |
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| ClinicalImpression.prognosis |
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| ClinicalImpression.plan |
|
See the Full Difference for further information
This analysis is available as XML or JSON.
See R2 <--> R3 Conversion Maps (status = 1 test that all execute ok. 1 fail round-trip testing and all r3 resources are valid.).
Structure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalImpression | DomainResource | A clinical assessment performed when planning treatments and management strategies for a patient Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | ||
| identifier | Σ | 0..* | Identifier | Business identifier |
| status | ?!Σ | 1..1 | code | draft | completed | entered-in-error ClinicalImpressionStatus (Required) |
| code | Σ | 0..1 | CodeableConcept | Kind of assessment performed |
| description | Σ | 0..1 | string | Why/how the assessment was performed |
| subject | Σ | 1..1 | Reference(Patient | Group) | Patient or group assessed |
| context | Σ | 0..1 | Reference(Encounter | EpisodeOfCare) | Encounter or Episode created from |
| effective[x] | Σ | 0..1 | Time of assessment | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| date | Σ | 0..1 | dateTime | When the assessment was documented |
| assessor | Σ | 0..1 | Reference(Practitioner) | The clinician performing the assessment |
| previous | 0..1 | Reference(ClinicalImpression) | Reference to last assessment | |
| problem | Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state |
| investigation | 0..* | BackboneElement | One or more sets of investigations (signs, symptions, etc.) | |
| code | 1..1 | CodeableConcept | A name/code for the set Investigation Type (Example) | |
| item | 0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy) | Record of a specific investigation | |
| protocol | 0..* | uri | Clinical Protocol followed | |
| summary | 0..1 | string | Summary of the assessment | |
| finding | 0..* | BackboneElement | Possible or likely findings and diagnoses | |
| item[x] | 1..1 | What was found Condition/Problem/Diagnosis Codes (Example) | ||
| itemCodeableConcept | CodeableConcept | |||
| itemReference | Reference(Condition | Observation) | |||
| basis | 0..1 | string | Which investigations support finding | |
| prognosisCodeableConcept | 0..* | CodeableConcept | Estimate of likely outcome Clinical Impression Prognosis (Example) | |
| prognosisReference | 0..* | Reference(RiskAssessment) | RiskAssessment expressing likely outcome | |
| action | 0..* | Reference(ReferralRequest | ProcedureRequest | Procedure | MedicationRequest | Appointment) | Action taken as part of assessment procedure | |
| note | 0..* | Annotation | Comments made about the ClinicalImpression | |
| Documentation for this format |
XML Template
<ClinicalImpression xmlns="http://hl7.org/fhir">
JSON Template
{
"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
}
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> .
Changes since DSTU2
| ClinicalImpression | |
| ClinicalImpression.identifier |
|
| ClinicalImpression.code |
|
| ClinicalImpression.subject |
|
| ClinicalImpression.context |
|
| ClinicalImpression.effective[x] |
|
| ClinicalImpression.investigation |
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| ClinicalImpression.investigation.code |
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| ClinicalImpression.investigation.item |
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| ClinicalImpression.protocol |
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| ClinicalImpression.finding.item[x] |
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| ClinicalImpression.finding.basis |
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| ClinicalImpression.prognosisCodeableConcept |
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| ClinicalImpression.prognosisReference |
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| ClinicalImpression.action |
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| ClinicalImpression.note |
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| ClinicalImpression.trigger[x] |
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| ClinicalImpression.investigations |
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| ClinicalImpression.finding.cause |
|
| ClinicalImpression.resolved |
|
| ClinicalImpression.ruledOut |
|
| ClinicalImpression.prognosis |
|
| ClinicalImpression.plan |
|
See the Full Difference for further information
This analysis is available as XML or JSON.
See R2 <--> R3 Conversion Maps (status = 1 test that all execute ok. 1 fail round-trip testing and all r3 resources are valid.).
Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle)
| Path | Definition | Type | Reference |
|---|---|---|---|
| ClinicalImpression.status | The workflow state of a clinical impression. | Required | ClinicalImpressionStatus |
| ClinicalImpression.code | Identifies categories of clinical impressions. This is a place-holder only. It may be removed | Unknown | No details provided yet |
| ClinicalImpression.investigation.code | A name/code for a set of investigations. | Example | Investigation Type |
| ClinicalImpression.finding.item[x] | Identification of the Condition or diagnosis. | Example | Condition/Problem/Diagnosis Codes |
| ClinicalImpression.prognosisCodeableConcept | Prognosis or outlook findings | Example | Clinical Impression Prognosis |
A known issue exists with circular references between Condition and ClinicalImpression, which is due to the low maturity level of ClinicalImpression. The Patient Care work group intends to address this issue when ClinicalImpression is considered substantially complete and ready for implementation.
Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
| Name | Type | Description | Expression | In Common |
| action | reference | Action taken as part of assessment procedure | ClinicalImpression.action (Appointment, ReferralRequest, MedicationRequest, ProcedureRequest, Procedure) | |
| assessor | reference | The clinician performing the assessment | ClinicalImpression.assessor (Practitioner) | |
| context | reference | Encounter or Episode created from | ClinicalImpression.context (EpisodeOfCare, Encounter) | |
| date | date | When the assessment was documented | ClinicalImpression.date | 18 Resources |
| finding-code | token | What was found | ClinicalImpression.finding.item.as(CodeableConcept) | |
| finding-ref | reference | What was found | ClinicalImpression.finding.item.as(Reference) (Condition, Observation) | |
| identifier | token | Business identifier | ClinicalImpression.identifier | |
| investigation | reference | Record of a specific investigation | ClinicalImpression.investigation.item (RiskAssessment, FamilyMemberHistory, Observation, DiagnosticReport, ImagingStudy, QuestionnaireResponse) | |
| patient | reference | Patient or group assessed | ClinicalImpression.subject (Patient) | 31 Resources |
| previous | reference | Reference to last assessment | ClinicalImpression.previous (ClinicalImpression) | |
| problem | reference | Relevant impressions of patient state | ClinicalImpression.problem (Condition, AllergyIntolerance) | |
| status | token | draft | completed | entered-in-error | ClinicalImpression.status | |
| subject | reference | Patient or group assessed | ClinicalImpression.subject (Group, Patient) |
®© HL7.org 2011+. FHIR Release 3 (STU; v3.0.2-11200) generated on Thurs, Oct 24, 2019 11:53+1100. QA Page
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