ClinicalImpression Profile¶
| Canonical | ../StructureDefinition/nexus-emr-core-clinicalimpression |
|---|---|
| Status | draft · 1.26.0 |
| Base | ClinicalImpression (constraint) |
| Source | FSH · 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.
Elements / Differential
What this profile constrains beyond ClinicalImpression. Anything not listed is unchanged from the base; muted type/cardinality values are the base's, shown for context.
| Element | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalImpression | Invariants: nexus-note-extension-not-where-native |
|||
| meta | 0..1 | Meta | ||
| source | S | 0..1 | uri | Identifies EMR instance & pipeline version the resource came from i |
| identifier | S | 0..* | Identifier | Business identifier(s) for clinicalimpression i |
| system | 1..1 | uri | i | |
| value | 1..1 | string | i | |
| status | S | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error i Binding: clinicalimpression-status ( required) |
| code | S | 0..1 | CodeableConcept | Assessment type with raw code support i |
| description | S | 1..1 | string | Assessment narrative from SOAP note i |
| subject | S | 1..1 | Reference(Patient Profile) | Patient being assessed i |
| encounter | S | 0..1 | Reference(Encounter Profile) | Encounter during which assessment was made i |
| date | S | 1..1 | dateTime | When assessment was recorded i |