ClinicalAssessment

Introduction

Scope and Usage

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 wide variance in how clinical assessments are recorded. Some clinical assessments simply result in an assessment 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 assessment can explicitly reference both care plans (preceding and resulting) and reference a previous assessment that this assessment follows.

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

In FHIR, an assessment is typically an instrument or tool used to collect information about a patient.

[%stu-note dstu%] Unlike many other resources, there is little prior art with regard to exchanging records of clinical assessments. For this reason, this resource should be regarded as particularly prone to ongoing revision. In terms of scope and usage, the Patient Care workgroup wishes to draw the attention of reviewers and implementers to the following issues:

• When is an existing clinical assessment revised, rather than a new one created (that references the existing one)? How does that affect the status? What's the interplay between the status of the diagnosis and the status of the assessment? (e.g. for a 'provisional' assessment, which bit is provisional?)
• This structure doesn't differentiate between a working and a final diagnosis. Given an answer to the previous question, should it?
• Further clarify around the relationship between care plan and assessment is needed. Both answers to the previous questions and ongoing discussions around revisions to the care plan will influence the design of clinical assessment
• Should prognosis be represented, and if so, how much structure should it have?
• Should an assessment reference other assessments that are related? (how related?)
• Investigations - the specification needs a good value set for the code for the group, and will be considering the name "investigations" further

Feedback is welcome here. [%end-note%]

Boundaries and Relationships

ClinicalAssessment is the equivalent of the "A" (assessment) in the SOAP note format originally described by Lawrence Weed, MD. It is the outcome of the clinical assessment process. The ClinicalAssessment may lead to a statement of a Condition about a patient. There is another related clinical concept often called an "assessment": assessment Tools such as Apgar (also known as "Assessment Scales"). This is not what the ClinicalAssessment resource is about; assessment tools such as Apgar are represented as Observations, and Questionnaires may be used to help generate these. Clinical assessments may refer to these assessment tools as one of the investigations that was performed during the assessment process.

Background and Context

An important background to understanding this resource is the FHIR Confluence page for clinical assessment. In particular, the storyboards there drove the design of the resource, and will be the basis for all examples created.

PLANNED CHANGE:

ClinicalAssessment is one of the Event resources in the FHIR Workflow specification. As such, it is expected to be adjusted to align with the Event workflow pattern which will involve adding a number of additional data elements and potentially renaming a few elements. Any concerns about performing such alignment are welcome as ballot comments and/or tracker items.

A known issue exists with circular references between Condition and ClinicalAssessment, which is due to the low maturity level of ClinicalAssessment. The Patient Care work group intends to address this issue when ClinicalAssessment is considered substantially complete and ready for implementation.

Notes

Known Issue

A known issue exists with circular references between Condition and ClinicalAssessment, which is due to the low maturity level of ClinicalAssessment. The Patient Care work group intends to address this issue when ClinicalAssessment is considered substantially complete and ready for implementation.

StructureDefinition

Elements (Simplified)

• ClinicalAssessment [0..*]: - A clinical assessment performed when planning treatments and management strategies for a patient
• ClinicalAssessment.identifier [0..*]: Identifier Business identifier
• ClinicalAssessment.status [1..1]: code required:event-status preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
• ClinicalAssessment.statusReason [0..1]: CodeableConcept example:clinicalassessment-status-reason Reason for current status
• ClinicalAssessment.description [0..1]: string Why/how the assessment was performed
• ClinicalAssessment.subject [1..1]: [Reference(Patient](/Reference(Patient), Group)) Patient or group assessed
• ClinicalAssessment.encounter [0..1]: Reference(Encounter) The Encounter during which this ClinicalAssessment was created
• ClinicalAssessment.effective[x] [0..1]: dateTime, Period Time of assessment
• ClinicalAssessment.date [0..1]: dateTime When the assessment was documented
• ClinicalAssessment.performer [0..1]: [Reference(Practitioner](/Reference(Practitioner), PractitionerRole)) The clinician performing the assessment
• ClinicalAssessment.previous [0..1]: Reference(ClinicalAssessment) Reference to last assessment
• ClinicalAssessment.problem [0..*]: [Reference(Condition](/Reference(Condition), AllergyIntolerance)) Relevant assessments of patient state
• ClinicalAssessment.changePattern [0..1]: CodeableConcept example:clinicalassessment-change-pattern Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change
• ClinicalAssessment.protocol [0..*]: uri Clinical Protocol followed
• ClinicalAssessment.summary [0..1]: markdown Text summary of the assessment
• ClinicalAssessment.finding [0..*]: BackboneElement Possible or likely findings and diagnoses
• ClinicalAssessment.finding.item [0..1]: CodeableReference example:condition-code What was found
• ClinicalAssessment.finding.basis [0..1]: string Which investigations support finding
• ClinicalAssessment.prognosis [0..*]: CodeableReference example:clinicalassessment-prognosis Estimate of likely outcome
• ClinicalAssessment.supportingInfo [0..*]: Reference(Resource) Information supporting the clinical assessment
• ClinicalAssessment.note [0..*]: Annotation Comments made about the ClinicalAssessment

Mappings

• ClinicalAssessment Mappings — 29 mapping entries

Resource Packs

list-ClinicalAssessment-packs.xml

<?xml version="1.0" encoding="UTF-8"?>

<List xmlns="http://hl7.org/fhir">
  <id value="ClinicalAssessment-packs"/>
  <status value="current"/>
  <mode value="working"/>
</List>

Search Parameters

• date — date — When the assessment was documented — ClinicalAssessment.date
• encounter — reference — The Encounter during which this ClinicalAssessment was created — ClinicalAssessment.encounter
• finding-code — token — Reference to a concept (by class) — ClinicalAssessment.finding.item.concept
• finding-ref — reference — Reference to a resource (by instance) — ClinicalAssessment.finding.item.reference
• identifier — token — Business identifier — ClinicalAssessment.identifier
• patient — reference — Patient assessed — ClinicalAssessment.subject.where(resolve() is Patient)
• performer — reference — The clinician performing the assessment — ClinicalAssessment.performer
• previous — reference — Reference to last assessment — ClinicalAssessment.previous
• problem — reference — Relevant impressions of patient state — ClinicalAssessment.problem
• status — token — preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown — ClinicalAssessment.status
• subject — reference — Patient or group assessed — ClinicalAssessment.subject
• supporting-info — reference — Information supporting the clinical impression — ClinicalAssessment.supportingInfo

Full Search Parameters

Examples

• clinicalassessment-example — clinicalassessment-example
• clinicalassessment-examples-header — clinicalassessment-examples-header
• example — clinicalassessment-example — Example of ClinicalAssessment

Full Examples

Mapping Exceptions

clinicalassessment-event-mapping-exceptions.xml

Divergent Elements

• Event.identifier → ClinicalAssessment.identifier
  • shortUnmatched | reason=Unknown | pattern=Business identifier for clinical assessment | resource=Business identifier
  • definitionUnmatched | reason=Unknown | pattern=Business identifiers assigned to this clinical assessment by the performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server. | resource=Business identifiers assigned to this clinical assessment by the performer or other systems which remain constant as the resource is updated and propagates from server to server.
  • commentsUnmatched | reason=Unknown | pattern=Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. | resource=This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
• Event.status → ClinicalAssessment.status
  • shortUnmatched | reason=Unknown | pattern=preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown | resource=preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
  • definitionUnmatched | reason=Unknown | pattern=The current state of the clinical assessment. | resource=Identifies the workflow status of the assessment.
  • commentsUnmatched | reason=Unknown | pattern=A nominal state-transition diagram can be found in the (Event pattern documentation

Unknown does not represent "other" - one of the defined statuses must apply. Unknown is used when the authoring system is not sure what the current status is. | resource=This element is labeled as a modifier because the status contains the code entered-in-error that marks the clinical assessment as not currently valid.

• Event.statusReason → ClinicalAssessment.statusReason
  • definitionUnmatched | reason=Unknown | pattern=Captures the reason for the current state of the clinical assessment. | resource=Captures the reason for the current state of the ClinicalAssessment.
  • commentsUnmatched | reason=Unknown | pattern=This is generally only used for "exception" statuses such as "not-done", "suspended" or "cancelled". The reason for performing the event at all is captured in reasonCode, not here. . | resource=This is generally only used for "exception" statuses such as "not-done", "on-hold" or "stopped".
• Event.subject → ClinicalAssessment.subject
  • shortUnmatched | reason=Unknown | pattern=Individual service was done for/to | resource=Patient or group assessed
  • definitionUnmatched | reason=Unknown | pattern=The individual or set of individuals the action is being or was performed on. | resource=The patient or group of individuals assessed as part of this record.
  • requirementsUnmatched | reason=Unknown | pattern=Links the clinical assessment to the Patient context. May also affect access control. | resource=Group is typically for veterinary and/or public health purposes.
• Event.encounter → ClinicalAssessment.encounter
  • shortUnmatched | reason=Unknown | pattern=Encounter the clinical assessment is part of | resource=The Encounter during which this ClinicalAssessment was created
  • definitionUnmatched | reason=Unknown | pattern=The Encounter during which this clinical assessment was created or to which the creation of this record is tightly associated. | resource=The Encounter during which this ClinicalAssessment was created or to which the creation of this record is tightly associated.
  • commentsUnmatched | reason=Unknown | pattern=This will typically be the encounter the clinical assessment was created during, but some clinical assessments may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission lab tests). | resource=This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
  • requirementsUnmatched | reason=Unknown | pattern=Links the clinical assessment to the Encounter context. May also affect access control.
• Event.occurrence[x] → ClinicalAssessment.effective[x]
  • missingTypes | reason=Unknown | pattern=Timing
  • shortUnmatched | reason=Unknown | pattern=When clinical assessment occurred/is occurring | resource=Time of assessment
  • definitionUnmatched | reason=Unknown | pattern=The date, period or timing when the clinical assessment did occur or is occurring. | resource=The point in time or period over which the subject was assessed.
  • commentsUnmatched | reason=Unknown | pattern=This indicates when the activity actually occurred or is occurring, not when it was asked/requested/ordered to occur. For the latter, look at the occurence element of the Request this {{event}} is "basedOn". The status code allows differentiation of whether the timing reflects a historic event or an ongoing event. Ongoing events should not include an upper bound in the Period or Timing.bounds. . | resource=This SHOULD be accurate to at least the minute, though some assessments only have a known date.
• Event.performer.actor → ClinicalAssessment.performer
  • missingTypes | reason=Unknown | pattern=Reference(Organization, CareTeam, Patient, Device, RelatedPerson)
  • shortUnmatched | reason=Unknown | pattern=Who performed clinical assessment | resource=The clinician performing the assessment
  • definitionUnmatched | reason=Unknown | pattern=Indicates who or what performed the clinical assessment. | resource=The clinician performing the assessment.
• Event.note → ClinicalAssessment.note
  • shortUnmatched | reason=Unknown | pattern=Comments made about the event | resource=Comments made about the ClinicalAssessment
  • definitionUnmatched | reason=Unknown | pattern=Comments made about the clinical assessment by the performer, subject or other participants. | resource=Commentary about the assessment, typically recorded after the assessment itself was made, though supplemental notes by the original author could also appear.

Unmapped Elements

• Event.partOf — Unknown
• Event.reported — Unknown
• Event.reason — Unknown
• Event.relevantHistory — Unknown
• Event.code — Unknown
• Event.location — Unknown
• Event.performer.function — Unknown
• Event.category — Unknown
• Event.recorded — Unknown
• Event.product — Unknown
• Event.performer — Unknown
• Event.basedOn — Unknown
• Event.researchStudy — Unknown

clinicalassessment-fivews-mapping-exceptions.xml

Unmapped Elements

• FiveWs.what — Unknown
• FiveWs.author — Unknown
• FiveWs.cause — Unknown
• FiveWs.version — Unknown
• FiveWs.witness — Unknown
• FiveWs.class — Unknown
• FiveWs.where — Unknown
• FiveWs.init — Unknown
• FiveWs.source — Unknown
• FiveWs.who — Unknown
• FiveWs.grade — Unknown
• FiveWs.planned — Unknown