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 / Snapshot
The full effective definition: base ClinicalImpression with this profile's constraints applied.
| 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 |
||
| id | 0..1 | http://hl7.org/fhirpath/System.String | Logical id of this artifact i | |
| meta | 0..1 | Meta | Metadata about the resource Invariants: ele-1 |
|
| id | 0..1 | http://hl7.org/fhirpath/System.String | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations i Slicing: value:url (open) Invariants: ele-1, ext-1 |
|
| versionId | 0..1 | id | Version specific identifier i Invariants: ele-1 |
|
| lastUpdated | 0..1 | instant | When the resource version last changed i Invariants: ele-1 |
|
| source | S | 0..1 | uri | Identifies EMR instance & pipeline version the resource came from i Invariants: ele-1 |
| profile | 0..* | canonical | Profiles this resource claims to conform to i Invariants: ele-1 |
|
| security | 0..* | Coding | Security Labels applied to this resource i Binding: security-labels ( extensible)Invariants: ele-1 |
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| tag | 0..* | Coding | Tags applied to this resource i Binding: common-tags ( example)Invariants: ele-1 |
|
| implicitRules | ?! | 0..1 | uri | A set of rules under which this content was created i Invariants: ele-1 |
| language | 0..1 | code | Language of the resource content i Binding: languages ( preferred)Invariants: ele-1 |
|
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation i Invariants: ele-1 |
|
| contained | 0..* | Resource | Contained, inline Resources i | |
| extension | 0..* | Extension | Additional content defined by implementations i Invariants: ele-1, ext-1 |
|
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored i Invariants: ele-1, ext-1 |
| identifier | S | 0..* | Identifier | Business identifier(s) for clinicalimpression i Invariants: ele-1 |
| id | 0..1 | http://hl7.org/fhirpath/System.String | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations i Slicing: value:url (open) Invariants: ele-1, ext-1 |
|
| use | ?! | 0..1 | code | usual | official | temp | secondary | old (If known) i Binding: identifier-use ( required)Invariants: ele-1 |
| type | 0..1 | CodeableConcept | Description of identifier i Binding: identifier-type ( extensible)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 |
|
| period | 0..1 | Period | Time period when id is/was valid for use Invariants: ele-1 |
|
| assigner | 0..1 | Reference(Organization) | Organization that issued id (may be just text) 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 |
| statusReason | 0..1 | CodeableConcept | Reason for current status i 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 |
| effective[x] | 0..1 | dateTime, Period | Time of assessment i Invariants: ele-1 |
|
| date | S | 1..1 | dateTime | When assessment was recorded i Invariants: ele-1 |
| assessor | 0..1 | Reference(Practitioner | PractitionerRole) | The clinician performing the assessment Invariants: ele-1 |
|
| previous | 0..1 | Reference(ClinicalImpression) | Reference to last assessment i Invariants: ele-1 |
|
| problem | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state i Invariants: ele-1 |
|
| investigation | 0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) Invariants: ele-1 |
|
| id | 0..1 | http://hl7.org/fhirpath/System.String | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations i Invariants: ele-1, ext-1 |
|
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored even if unrecognized i Invariants: ele-1, ext-1 |
| code | 1..1 | CodeableConcept | A name/code for the set Binding: investigation-sets ( example)Invariants: ele-1 |
|
| item | 0..* | Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media) | Record of a specific investigation i Invariants: ele-1 |
|
| protocol | 0..* | uri | Clinical Protocol followed Invariants: ele-1 |
|
| summary | 0..1 | string | Summary of the assessment Invariants: ele-1 |
|
| finding | 0..* | BackboneElement | Possible or likely findings and diagnoses Invariants: ele-1 |
|
| id | 0..1 | http://hl7.org/fhirpath/System.String | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations i Invariants: ele-1, ext-1 |
|
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored even if unrecognized i Invariants: ele-1, ext-1 |
| itemCodeableConcept | 0..1 | CodeableConcept | What was found Binding: condition-code ( example)Invariants: ele-1 |
|
| itemReference | 0..1 | Reference(Condition | Observation | Media) | What was found Invariants: ele-1 |
|
| basis | 0..1 | string | Which investigations support finding Invariants: ele-1 |
|
| prognosisCodeableConcept | 0..* | CodeableConcept | Estimate of likely outcome Binding: clinicalimpression-prognosis ( example)Invariants: ele-1 |
|
| prognosisReference | 0..* | Reference(RiskAssessment) | RiskAssessment expressing likely outcome Invariants: ele-1 |
|
| supportingInfo | 0..* | Reference(Resource) | Information supporting the clinical impression Invariants: ele-1 |
|
| note | 0..* | Annotation | Comments made about the ClinicalImpression i Invariants: ele-1 |