Clinical Impression

$10 / year

Clinical Impression is a record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient’s condition. Assessments are often 1:1 with a clinical consultation/encounter, but this varies greatly depending on the clinical workflow.

Complexity

Performing a clinical assessment is a fundamental part of a clinician’s workflow, performed repeatedly throughout the day. In spite of this – or perhaps, because of it – there is a wide variance in how clinical impressions are recorded. Some clinical assessments simply result in an impression recorded as a single text note in the patient ‘record’ (e.g. “Progress satisfactory, continue with treatment”), while others are associated with careful, detailed record keeping of the evidence gathered and the reasoning leading to a differential diagnosis, and there is a continuum between these. This resource is intended to be used to cover all these use cases.

The assessment is intimately linked to the process of care. It may occur in the context of a care plan, and it very often results in a new (or revised) care plan. Normally, clinical assessments are part of an ongoing process of care, and the patient will be re-assessed repeatedly. For this reason, the clinical impression can explicitly reference both care plans (preceding and resulting) and reference a previous impression that this impression follows.

An impression is a clinical summation of information and/or an opinion formed, which is the outcome of the clinical assessment process. The Clinical Impression may lead to a statement of a Condition about a patient.

Fast Healthcare Interoperability Resources (FHIR) is a draft standard describing data formats and elements (known as “resources”) and an application programming interface (API) for exchanging electronic health records. The standard was created by the Health Level Seven International (HL7) health-care standards organization.

Its goal is to facilitate interoperation between legacy healthcare systems, to make it easy to provide healthcare information to healthcare providers and individuals on a wide variety of devices from computers to tablets to cell phones, and to allow third-party application developers to provide medical applications which can be easily integrated into existing systems.

FHIR provides an alternative to document-centric approaches by directly exposing discrete data elements as services. For example, basic elements of healthcare like patients, admissions, diagnostic reports and medications can each be retrieved and manipulated via their own resource URLs (Uniform Resource Locators). FHIR was supported at an American Medical Informatics Association meeting by many EHR (Electronic Health Record) vendors which value its open and extensible nature.

Date Created

2018-09-20

Last Modified

2019-11-01

Version

4.0.1

Update Frequency

Annual

Temporal Coverage

N/A

Spatial Coverage

United States

Source

John Snow Labs; Health Level Seven International;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

FHIR, HL7, Medical Terminology, Processes Data, Processes Information, Processes Documentation, Health Information Exchange, Electronic Health Records, FHIR Smart, Smart on FHIR

Other Titles

FHIR Clinical Impression Resource, Electronic Health Records Exchange Through FHIR

NameDescriptionTypeConstraints
Concept_NameName of the concept in the FHIR structurestringrequired : 1
Computer_Ready_NameA Computer-ready name (e.g. a token) that identifies the structure - suitable for code generation. Note that this name (and other names relevant for code generation, including element & slice names, codes etc) may collide with reserved words in the relevant target language, and code generators will need to handle this.string-
TypeThe type the structure describes.string-
Dollar_RefThe Dollar_Ref ($ref) string value contains a Uniform Resource Identifier (URI) which identifies the location of the JSON (JavaScript Object Notation) value being referenced.string-
DescriptionA free text natural language description of the structure and its usestring-
ItemsThe value of the keyword should be an object or an array of objects. If the keyword value is an object, then for the data array to be valid each item of the array should be valid according to the schema in this value.string-
RequiredThe value of the keyword should be an array of unique strings. The data object to be valid should contain all properties with names equal to the elements in the keyword value.string-
ConstThe value of this keyword can be anything. The data is valid if it is deeply equal to the value of the keyword.string-
Concept NameComputer Ready NameTypeDollar RefDescriptionItemsRequiredConst
ClinicalImpressionresourceTypeThis is a ClinicalImpression resourceClinicalImpression
ClinicalImpressionid#/definitions/idThe logical id of the resource as used in the URL for the resource. Once assigned this value never changes.
ClinicalImpressionmeta#/definitions/MetaThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
ClinicalImpressionimplicitRules#/definitions/uriA reference to a set of rules that were followed when the resource was constructed and which must be understood when processing the content. Often this is a reference to an implementation guide that defines the special rules along with other profiles etc.
ClinicalImpression_implicitRules#/definitions/ElementExtensions for implicitRules
ClinicalImpressionlanguage#/definitions/codeThe base language in which the resource is written.
ClinicalImpression_language#/definitions/ElementExtensions for language
ClinicalImpressiontext#/definitions/NarrativeA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
ClinicalImpressioncontainedarrayThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently and nor can they have their own independent transaction scope.{'$ref': '#/definitions/ResourceList'}
ClinicalImpressionextensionarrayMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension there is a set of requirements that SHALL be met as part of the definition of the extension.{'$ref': '#/definitions/Extension'}
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