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 / Key elements
The working view: must-support, required, modifier and sliced elements from the effective (snapshot) definition.
| Element | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClinicalImpression | 0..* | A clinical assessment performed when planning treatments and management strategies for a patient Invariants: dom-2, dom-3, dom-4, dom-5, dom-6, nexus-note-extension-not-where-native |
||
| meta | 0..1 | Meta | Metadata about the resource Invariants: ele-1 |
|
| source | S | 0..1 | uri | Identifies EMR instance & pipeline version the resource came from i Invariants: ele-1 |
| implicitRules | ?! | 0..1 | uri | A set of rules under which this content was created i Invariants: ele-1 |
| identifier | S | 0..* | Identifier | Business identifier(s) for clinicalimpression i Invariants: ele-1 |
| use | ?! | 0..1 | code | usual | official | temp | secondary | old (If known) i Binding: identifier-use ( required)Invariants: ele-1 |
| system | 1..1 | uri | The namespace for the identifier value i Invariants: ele-1 |
|
| value | 1..1 | string | The value that is unique i Invariants: ele-1 |
|
| status | S ?! | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error i Binding: clinicalimpression-status ( required)Invariants: ele-1 |
| code | S | 0..1 | CodeableConcept | Assessment type with raw code support i Invariants: ele-1 |
| description | S | 1..1 | string | Assessment narrative from SOAP note i Invariants: ele-1 |
| subject | S | 1..1 | Reference(Patient Profile) | Patient being assessed i Invariants: ele-1 |
| encounter | S | 0..1 | Reference(Encounter Profile) | Encounter during which assessment was made i Invariants: ele-1 |
| date | S | 1..1 | dateTime | When assessment was recorded i Invariants: ele-1 |
| investigation | 0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) Invariants: ele-1 |
|
| code | 1..1 | CodeableConcept | A name/code for the set Binding: investigation-sets ( example)Invariants: ele-1 |