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ClinicalImpression Profile

Canonical../StructureDefinition/nexus-emr-core-clinicalimpression
Statusdraft · 1.26.0
BaseClinicalImpression (constraint)
SourceFSH · JSON

Nexus EMR profile for ClinicalImpression capturing the Assessment section of a SOAP encounter note. Purpose: export assessment text. Should be exported by EMRs that have the ability to parse the 'A' text out of a SOAP note.

Examples

Avery clinicalimpression 20250408

Assessment: Patient presents with acute symptomatic anemia (hemoglobin 68 g/L) following new-onset dizziness and fatigue. Iron therapy prescribed (ferrous sulfate 325 mg daily) and follow-up assessment scheduled in two weeks.

ClinicalImpression/avery-clinicalimpression-20250408 — claims conformance to ClinicalImpression Profile

{
  "resourceType": "ClinicalImpression",
  "id": "avery-clinicalimpression-20250408",
  "meta": {
    "profile": [
      "../StructureDefinition/nexus-emr-core-clinicalimpression"
    ]
  },
  "identifier": [
    {
      "use": "secondary",
      "system": "../NamingSystem/cedarbrook-clinic-clinicalimpression-raw-code",
      "value": "EMR-CI-AVERY-20250408"
    }
  ],
  "status": "completed",
  "subject": {
    "reference": "Patient/avery-linwood",
    "display": "Avery Linwood"
  },
  "date": "2025-04-08T09:50:00-06:00",
  "description": "Assessment: Patient presents with acute symptomatic anemia (hemoglobin 68 g/L) following new-onset dizziness and fatigue. Iron therapy prescribed (ferrous sulfate 325 mg daily) and follow-up assessment scheduled in two weeks.",
  "encounter": {
    "reference": "Encounter/enc-avery-20250408-01rc",
    "display": "Annual wellness visit for Avery Linwood on April 8 2025"
  },
  "assessor": {
    "reference": "Practitioner/dr-emil-navarro",
    "display": "Dr. Emil Navarro"
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns='http://www.w3.org/1999/xhtml'><p>ClinicalImpression for acute symptomatic anemia in Avery Linwood on April 8 2025. Hemoglobin measured at 68 g/L, iron therapy initiated by Dr Emil Navarro.</p></div>"
  }
}