---
type: "resource-definitions"
title: "ClinicalAssessment Definitions"
resource: "ClinicalAssessment"
---

# ClinicalAssessment Definitions

<a id="ClinicalAssessment"></a>

## 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


<a id="ClinicalAssessment.identifier"></a>

## 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](resource.html#identifiers)).  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](/Identifier)

**Summary:** true

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


<a id="ClinicalAssessment.status"></a>

## ClinicalAssessment.status
preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown

**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](/code)

**Binding:** required:[event-status](/valueset-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


<a id="ClinicalAssessment.statusReason"></a>

## 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](/CodeableConcept)

**Binding:** example:[clinicalassessment-status-reason](/valueset-clinicalassessment-status-reason)

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


<a id="ClinicalAssessment.description"></a>

## 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](/string)

**Summary:** true


<a id="ClinicalAssessment.subject"></a>

## 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](/Patient), [Group](/Group))

**Summary:** true

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


<a id="ClinicalAssessment.encounter"></a>

## 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](/Encounter))

**Summary:** true

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


<a id="ClinicalAssessment.effective[x]"></a>

## 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](/dateTime), [Period](/Period)

**Summary:** true

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


<a id="ClinicalAssessment.date"></a>

## ClinicalAssessment.date
When the assessment was documented

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

**Cardinality:** 0..1

**Type:** [dateTime](/dateTime)

**Summary:** true

**Mappings:** w5=FiveWs.recorded


<a id="ClinicalAssessment.performer"></a>

## ClinicalAssessment.performer
The clinician performing the assessment

**Definition:** The clinician performing the assessment.

**Cardinality:** 0..1

**Type:** Reference([Practitioner](/Practitioner), [PractitionerRole](/PractitionerRole))

**Summary:** true

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


<a id="ClinicalAssessment.previous"></a>

## 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))


<a id="ClinicalAssessment.problem"></a>

## 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](/Condition), [AllergyIntolerance](/AllergyIntolerance))

**Summary:** true

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


<a id="ClinicalAssessment.changePattern"></a>

## 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](/CodeableConcept)

**Binding:** example:[clinicalassessment-change-pattern](/valueset-clinicalassessment-change-pattern)


<a id="ClinicalAssessment.protocol"></a>

## 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](/uri)


<a id="ClinicalAssessment.summary"></a>

## ClinicalAssessment.summary
Text summary of the assessment

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

**Cardinality:** 0..1

**Type:** [markdown](/markdown)

**Mappings:** v2=OBX


<a id="ClinicalAssessment.finding"></a>

## 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](/BackboneElement)


<a id="ClinicalAssessment.finding.item"></a>

## 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](/CodeableReference)

**Binding:** example:[condition-code](/valueset-condition-code)

**Mappings:** v2=OBX


<a id="ClinicalAssessment.finding.basis"></a>

## ClinicalAssessment.finding.basis
Which investigations support finding

**Definition:** Which investigations support finding or diagnosis.

**Cardinality:** 0..1

**Type:** [string](/string)


<a id="ClinicalAssessment.prognosis"></a>

## ClinicalAssessment.prognosis
Estimate of likely outcome

**Definition:** Estimate of likely outcome.

**Cardinality:** 0..*

**Type:** [CodeableReference](/CodeableReference)

**Binding:** example:[clinicalassessment-prognosis](/valueset-clinicalassessment-prognosis)

**Mappings:** v2=PRB-22


<a id="ClinicalAssessment.supportingInfo"></a>

## ClinicalAssessment.supportingInfo
Information supporting the clinical assessment

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

**Cardinality:** 0..*

**Type:** Reference([Resource](/Resource))


<a id="ClinicalAssessment.note"></a>

## 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](/Annotation)

**Mappings:** workflow=Event.note