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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.

Overview

Overview

The Nexus EMR Core ClinicalImpression profile represents clinical assessments and impressions within primary care EMR systems. This profile specifically captures the Assessment ('A') section from SOAP (Subjective, Objective, Assessment, Plan) encounter notes, providing structured access to clinical reasoning and diagnostic thinking across the Nexus EMR ecosystem.

Key Features

  • SOAP Note Integration: Extracts and structures the Assessment portion of SOAP documentation
  • Free-text Narrative: Preserves clinical reasoning in narrative form
  • Status Tracking: Monitors whether assessment is draft, completed, or in-progress
  • Encounter Linkage: Connects assessments to specific clinical encounters
  • Flexible Coding: Supports both standard and EMR-specific assessment type codes

Clinical Purpose

The ClinicalImpression serves to:

  • Document clinical reasoning and diagnostic thinking
  • Capture differential diagnoses consideration
  • Record clinical synthesis of findings
  • Provide assessment narrative for care coordination
  • Support clinical decision-making documentation

SOAP Note Context

In SOAP documentation:

  • Subjective: Patient's complaints and history
  • Objective: Physical findings and test results
  • Assessment: Clinical impression and reasoning (captured here)
  • Plan: Treatment and follow-up plans

This profile focuses on extracting and structuring the Assessment component for systems that can parse SOAP notes.

Status Management

Assessment states include:

  • Preparation: Assessment being formulated
  • In-progress: Assessment underway
  • Completed: Final assessment documented
  • Entered-in-error: Erroneous entry to ignore
  • On-hold: Assessment temporarily suspended
  • Stopped: Assessment terminated

Clinical Workflow

The profile supports:

  • Encounter-based assessments
  • Progress note documentation
  • Consultation assessments
  • Diagnostic reasoning capture
  • Clinical summary generation

Data Export Considerations

This profile is specifically designed for EMRs that can:

  • Parse structured SOAP notes
  • Extract Assessment text separately
  • Export assessment narratives
  • Link assessments to encounters

Systems without SOAP parsing capabilities may not implement this profile.

Terminology bindings

Path Strength Value set
ClinicalImpression.status required clinicalimpression-status