Guia de Implementação do AnHealth - Local Development build (v0.2.0). See the Directory of published versions

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Resource Profile: ClinicalImpression

Usage:

• This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
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This structure is derived from ClinicalImpression

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
subject	Σ	1..1	Reference(Patient | Group)	Patient or group assessed
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClinicalImpression.status	required	ClinicalImpressionStatus

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClinicalImpression	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClinicalImpression	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where(((id.exists() and ('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url)))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(uri) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClinicalImpression	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): IETF language tag Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business identifier
status	?!Σ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
statusReason		0..1	CodeableConcept	Reason for current status Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.
code	Σ	0..1	CodeableConcept	Kind of assessment performed Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
description	Σ	0..1	string	Why/how the assessment was performed
subject	Σ	1..1	Reference(Patient | Group)	Patient or group assessed
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
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 | PractitionerRole)	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, symptoms, etc.)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations.
item		0..*	Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)	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
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemCodeableConcept		0..1	CodeableConcept	What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
itemReference		0..1	Reference(Condition | Observation | Media)	What was found
basis		0..1	string	Which investigations support finding
prognosisCodeableConcept		0..*	CodeableConcept	Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
prognosisReference		0..*	Reference(RiskAssessment)	RiskAssessment expressing likely outcome
supportingInfo		0..*	Reference(Resource)	Information supporting the clinical impression
note		0..*	Annotation	Comments made about the ClinicalImpression
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClinicalImpression.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClinicalImpression.status	required	ClinicalImpressionStatus
ClinicalImpression.statusReason	example
ClinicalImpression.code	example
ClinicalImpression.investigation.code	example	InvestigationType
ClinicalImpression.finding.itemCodeableConcept	example	Condition/Problem/DiagnosisCodes
ClinicalImpression.prognosisCodeableConcept	example	ClinicalImpressionPrognosis

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-r4b	warning	ClinicalImpression.contained	Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems : ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClinicalImpression

Summary

Differential View

This structure is derived from ClinicalImpression

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
subject	Σ	1..1	Reference(Patient | Group)	Patient or group assessed
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClinicalImpression.status	required	ClinicalImpressionStatus

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClinicalImpression	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClinicalImpression	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where(((id.exists() and ('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url)))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(uri) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClinicalImpression	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClinicalImpression	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
ClinicalImpression		0..*	ClinicalImpression	A clinical assessment performed when planning treatments and management strategies for a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): IETF language tag Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business identifier
status	?!Σ	1..1	code	in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.
statusReason		0..1	CodeableConcept	Reason for current status Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.
code	Σ	0..1	CodeableConcept	Kind of assessment performed Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
description	Σ	0..1	string	Why/how the assessment was performed
subject	Σ	1..1	Reference(Patient | Group)	Patient or group assessed
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
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 | PractitionerRole)	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, symptoms, etc.)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	CodeableConcept	A name/code for the set Binding: InvestigationType (example): A name/code for a set of investigations.
item		0..*	Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)	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
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemCodeableConcept		0..1	CodeableConcept	What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.
itemReference		0..1	Reference(Condition | Observation | Media)	What was found
basis		0..1	string	Which investigations support finding
prognosisCodeableConcept		0..*	CodeableConcept	Estimate of likely outcome Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
prognosisReference		0..*	Reference(RiskAssessment)	RiskAssessment expressing likely outcome
supportingInfo		0..*	Reference(Resource)	Information supporting the clinical impression
note		0..*	Annotation	Comments made about the ClinicalImpression
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClinicalImpression.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClinicalImpression.status	required	ClinicalImpressionStatus
ClinicalImpression.statusReason	example
ClinicalImpression.code	example
ClinicalImpression.investigation.code	example	InvestigationType
ClinicalImpression.finding.itemCodeableConcept	example	Condition/Problem/DiagnosisCodes
ClinicalImpression.prognosisCodeableConcept	example	ClinicalImpressionPrognosis

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-r4b	warning	ClinicalImpression.contained	Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems : ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClinicalImpression

Summary

Other representations of profile: CSV, Excel, Schematron