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.