type: resource-definitionsresource: ClinicalAssessment

ClinicalAssessment Definitions

ClinicalAssessment

A clinical assessment performed when planning treatments and management strategies for a patient

Definition: 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.

Cardinality: 0..*

Mappings: workflow=Event; v2=Partial mapping for problem evaluation; w5=clinical.general

ClinicalAssessment.identifier

Business identifier

Definition: 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.

Comments: 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.

Requirements: Allows identification of the clinical assessment as it is known by various participating systems and in a way that remains consistent across servers.

Cardinality: 0..*

Type: Identifier

Summary: true

Mappings: workflow=Event.identifier; w5=FiveWs.identifier; v2=PID-3

ClinicalAssessment.status

Definition: Identifies the workflow status of the assessment.

Comments: 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.

Cardinality: 1..1

Type: code

Binding: required:event-status

Summary: true

Is Modifier: true (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)

Mappings: workflow=Event.status; w5=FiveWs.status; v2=PRB-14

ClinicalAssessment.statusReason

Reason for current status

Definition: Captures the reason for the current state of the ClinicalAssessment.

Comments: This is generally only used for "exception" statuses such as "not-done", "on-hold" or "stopped".

Aliases: Suspended Reason, Cancelled Reason

Cardinality: 0..1

Type: CodeableConcept

Binding: example:clinicalassessment-status-reason

Mappings: workflow=Event.statusReason; rim=.inboundRelationship[typeCode=SUBJ].source[classCode=CACT, moodCode=EVN].reasonCOde

ClinicalAssessment.description

Why/how the assessment was performed

Definition: A summary of the context and/or cause of the assessment - why / where it was performed, and what patient events/status prompted it.

Cardinality: 0..1

Type: string

Summary: true

ClinicalAssessment.subject

Patient or group assessed

Definition: The patient or group of individuals assessed as part of this record.

Requirements: Group is typically for veterinary and/or public health purposes.

Cardinality: 1..1

Type: Reference(Patient, Group)

Summary: true

Mappings: workflow=Event.subject; w5=FiveWs.subject; v2=PID-3

ClinicalAssessment.encounter

The Encounter during which this ClinicalAssessment was created

Definition: The Encounter during which this ClinicalAssessment was created or to which the creation of this record is tightly associated.

Comments: 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.

Cardinality: 0..1

Type: Reference(Encounter)

Summary: true

Mappings: workflow=Event.encounter; w5=FiveWs.context

ClinicalAssessment.effective[x]

Time of assessment

Definition: The point in time or period over which the subject was assessed.

Comments: This SHOULD be accurate to at least the minute, though some assessments only have a known date.

Cardinality: 0..1

Type: dateTime, Period

Summary: true

Mappings: workflow=Event.occurrence[x]; w5=FiveWs.done[x]; v2=PRB-2

ClinicalAssessment.date

When the assessment was documented

Definition: Indicates when the documentation of the assessment was complete.

Cardinality: 0..1

Type: dateTime

Summary: true

Mappings: w5=FiveWs.recorded

ClinicalAssessment.performer

The clinician performing the assessment

Definition: The clinician performing the assessment.

Cardinality: 0..1

Type: Reference(Practitioner, PractitionerRole)

Summary: true

Mappings: workflow=Event.performer.actor; w5=FiveWs.actor; v2=ROL-4

ClinicalAssessment.previous

Reference to last assessment

Definition: A reference to the last assessment that was conducted on this patient. Assessments are often/usually ongoing in nature; a care provider (practitioner or team) will make new assessments on an ongoing basis as new data arises or the patient's conditions changes.

Comments: It is always likely that multiple previous assessments exist for a patient. The point of quoting a previous assessment is that this assessment is relative to it (see resolved).

Cardinality: 0..1

Type: Reference(ClinicalAssessment)

ClinicalAssessment.problem

Relevant assessments of patient state

Definition: A list of the relevant problems/conditions for a patient.

Comments: e.g. The patient is a pregnant, has congestive heart failure, has an ‎Adenocarcinoma, and is allergic to penicillin.

Cardinality: 0..*

Type: Reference(Condition, AllergyIntolerance)

Summary: true

Mappings: w5=FiveWs.why[x]; v2=PRB-3 / IAM-7

ClinicalAssessment.changePattern

Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change

Definition: Change in the status/pattern of a subject's condition since previously assessed, such as worsening, improving, or no change. It is a subjective assessment of the direction of the change.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:clinicalassessment-change-pattern

ClinicalAssessment.protocol

Clinical Protocol followed

Definition: Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis.

Cardinality: 0..*

Type: uri

ClinicalAssessment.summary

Text summary of the assessment

Definition: A text summary of the investigations and the diagnosis.

Cardinality: 0..1

Type: markdown

Mappings: v2=OBX

ClinicalAssessment.finding

Possible or likely findings and diagnoses

Definition: Specific findings or diagnoses that were considered likely or relevant to ongoing treatment.

Cardinality: 0..*

Type: BackboneElement

ClinicalAssessment.finding.item

What was found

Definition: Specific text, code or reference for finding or diagnosis, which may include ruled-out or resolved conditions.

Cardinality: 0..1

Type: CodeableReference

Binding: example:condition-code

Mappings: v2=OBX

ClinicalAssessment.finding.basis

Which investigations support finding

Definition: Which investigations support finding or diagnosis.

Cardinality: 0..1

Type: string

ClinicalAssessment.prognosis

Estimate of likely outcome

Definition: Estimate of likely outcome.

Cardinality: 0..*

Type: CodeableReference

Binding: example:clinicalassessment-prognosis

Mappings: v2=PRB-22

ClinicalAssessment.supportingInfo

Information supporting the clinical assessment

Definition: Information supporting the clinical assessment, which can contain investigation results.

Cardinality: 0..*

Type: Reference(Resource)

ClinicalAssessment.note

Comments made about the ClinicalAssessment

Definition: Commentary about the assessment, typically recorded after the assessment itself was made, though supplemental notes by the original author could also appear.

Comments: Don't use this element for content that should more properly appear as one of the specific elements of the assessment.

Cardinality: 0..*

Type: Annotation

Mappings: workflow=Event.note