Руководство к использованию стандарта FHIR в МИС2
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Руководство к использованию стандарта FHIR в МИС2 - Local Development build (v0.5.0). See the Directory of published versions

Resource Profile: UZBaseClinicalImpressionFinding

Official URL: https://ssv.uz/fhir/StructureDefinition/UZBaseClinicalImpressionFinding Version: 0.5.0
Active as of 2023-04-04 Computable Name: UZBaseClinicalImpressionFinding

UZBase ClinicalImpression Finding. Клинический осмотр.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... status 1..1codein-progress | completed | entered-in-error
Fixed Value: completed
... code S1..1CodeableConceptKind of assessment performed
Fixed Value: As shown
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 75321-0
..... display1..1stringRepresentation defined by the system
Fixed Value: Clinical finding
... subject S1..1Reference(Patient | Group)Patient or group assessed
... summary S0..1stringSummary of the assessment

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1codein-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.


Fixed Value: completed
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 75321-0
..... display1..1stringRepresentation defined by the system
Fixed Value: Clinical finding
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... subject SΣ1..1Reference(Patient | Group)Patient or group assessed
... encounter SΣ0..1Reference(Encounter)Encounter created as part of
... summary S0..1stringSummary of the assessment

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalImpression.statusrequiredFixed Value: completed
ClinicalImpression.codeexampleFixed Value: LOINC code 75321-0("Clinical finding")
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier
... status ?!Σ1..1codein-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.


Fixed Value: completed
... statusReason 0..1CodeableConceptReason for current status
Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.

... code SΣ1..1CodeableConceptKind of assessment performed
Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.


Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 75321-0
..... display1..1stringRepresentation defined by the system
Fixed Value: Clinical finding
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... description Σ0..1stringWhy/how the assessment was performed
... subject SΣ1..1Reference(Patient | Group)Patient or group assessed
... encounter SΣ0..1Reference(Encounter)Encounter created as part of
... effective[x] Σ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... date Σ0..1dateTimeWhen the assessment was documented
... assessor Σ0..1Reference(Practitioner | PractitionerRole)The clinician performing the assessment
... previous 0..1Reference(ClinicalImpression)Reference to last assessment
... problem Σ0..*Reference(Condition | AllergyIntolerance)Relevant impressions of patient state
... investigation 0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1CodeableConceptA name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.

.... item 0..*Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)Record of a specific investigation
... protocol 0..*uriClinical Protocol followed
... summary S0..1stringSummary of the assessment
... finding 0..*BackboneElementPossible or likely findings and diagnoses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1CodeableConceptWhat was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.

.... itemReference 0..1Reference(Condition | Observation | Media)What was found
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.


... prognosisReference 0..*Reference(RiskAssessment)RiskAssessment expressing likely outcome
... supportingInfo 0..*Reference(Resource)Information supporting the clinical impression
... note 0..*AnnotationComments made about the ClinicalImpression

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalImpression.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClinicalImpression.statusrequiredFixed Value: completed
ClinicalImpression.statusReasonexample
ClinicalImpression.codeexampleFixed Value: LOINC code 75321-0("Clinical finding")
ClinicalImpression.investigation.codeexampleInvestigationType
ClinicalImpression.finding.itemCodeableConceptexampleCondition/Problem/DiagnosisCodes
ClinicalImpression.prognosisCodeableConceptexampleClinicalImpressionPrognosis

This structure is derived from ClinicalImpression

Summary

Mandatory: 1 element
Must-Support: 4 elements
Fixed Value: 2 elements

Differential View

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... status 1..1codein-progress | completed | entered-in-error
Fixed Value: completed
... code S1..1CodeableConceptKind of assessment performed
Fixed Value: As shown
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 75321-0
..... display1..1stringRepresentation defined by the system
Fixed Value: Clinical finding
... subject S1..1Reference(Patient | Group)Patient or group assessed
... summary S0..1stringSummary of the assessment

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1codein-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.


Fixed Value: completed
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 75321-0
..... display1..1stringRepresentation defined by the system
Fixed Value: Clinical finding
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... subject SΣ1..1Reference(Patient | Group)Patient or group assessed
... encounter SΣ0..1Reference(Encounter)Encounter created as part of
... summary S0..1stringSummary of the assessment

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalImpression.statusrequiredFixed Value: completed
ClinicalImpression.codeexampleFixed Value: LOINC code 75321-0("Clinical finding")

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier
... status ?!Σ1..1codein-progress | completed | entered-in-error
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.


Fixed Value: completed
... statusReason 0..1CodeableConceptReason for current status
Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.

... code SΣ1..1CodeableConceptKind of assessment performed
Binding: (unbound) (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.


Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 75321-0
..... display1..1stringRepresentation defined by the system
Fixed Value: Clinical finding
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... description Σ0..1stringWhy/how the assessment was performed
... subject SΣ1..1Reference(Patient | Group)Patient or group assessed
... encounter SΣ0..1Reference(Encounter)Encounter created as part of
... effective[x] Σ0..1Time of assessment
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... date Σ0..1dateTimeWhen the assessment was documented
... assessor Σ0..1Reference(Practitioner | PractitionerRole)The clinician performing the assessment
... previous 0..1Reference(ClinicalImpression)Reference to last assessment
... problem Σ0..*Reference(Condition | AllergyIntolerance)Relevant impressions of patient state
... investigation 0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1CodeableConceptA name/code for the set
Binding: InvestigationType (example): A name/code for a set of investigations.

.... item 0..*Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment | ImagingStudy | Media)Record of a specific investigation
... protocol 0..*uriClinical Protocol followed
... summary S0..1stringSummary of the assessment
... finding 0..*BackboneElementPossible or likely findings and diagnoses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1CodeableConceptWhat was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.

.... itemReference 0..1Reference(Condition | Observation | Media)What was found
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.


... prognosisReference 0..*Reference(RiskAssessment)RiskAssessment expressing likely outcome
... supportingInfo 0..*Reference(Resource)Information supporting the clinical impression
... note 0..*AnnotationComments made about the ClinicalImpression

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClinicalImpression.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClinicalImpression.statusrequiredFixed Value: completed
ClinicalImpression.statusReasonexample
ClinicalImpression.codeexampleFixed Value: LOINC code 75321-0("Clinical finding")
ClinicalImpression.investigation.codeexampleInvestigationType
ClinicalImpression.finding.itemCodeableConceptexampleCondition/Problem/DiagnosisCodes
ClinicalImpression.prognosisCodeableConceptexampleClinicalImpressionPrognosis

This structure is derived from ClinicalImpression

Summary

Mandatory: 1 element
Must-Support: 4 elements
Fixed Value: 2 elements

 

Other representations of profile: CSV, Excel, Schematron