Руководство к использованию стандарта FHIR в МИС2
0.5.0 - ci-build
Руководство к использованию стандарта FHIR в МИС2 - Local Development build (v0.5.0). See the Directory of published versions
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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClinicalImpression
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
status | 1..1 | code | in-progress | completed | entered-in-error Fixed Value: completed | |
code | S | 1..1 | CodeableConcept | Kind of assessment performed Fixed Value: As shown |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75321-0 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical finding | |
subject | S | 1..1 | Reference(Patient | Group) | Patient or group assessed |
encounter | S | 0..1 | Reference(Encounter) | Encounter created as part of |
summary | S | 0..1 | string | Summary of the assessment |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Fixed Value: completed |
code | SΣ | 1..1 | CodeableConcept | Kind 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 |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75321-0 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical finding | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
subject | SΣ | 1..1 | Reference(Patient | Group) | Patient or group assessed |
encounter | SΣ | 0..1 | Reference(Encounter) | Encounter created as part of |
summary | S | 0..1 | string | Summary of the assessment |
Documentation for this format |
Path | Conformance | ValueSet / Code |
ClinicalImpression.status | required | Fixed Value: completed |
ClinicalImpression.code | example | Fixed Value: LOINC code 75321-0("Clinical finding") |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier | ||||
status | ?!Σ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Fixed Value: completed | ||||
statusReason | 0..1 | CodeableConcept | Reason for current status Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression. | |||||
code | SΣ | 1..1 | CodeableConcept | Kind 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 | ||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75321-0 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical finding | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
description | Σ | 0..1 | string | Why/how the assessment was performed | ||||
subject | SΣ | 1..1 | Reference(Patient | Group) | Patient or group assessed | ||||
encounter | SΣ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
effective[x] | Σ | 0..1 | Time of assessment | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
date | Σ | 0..1 | dateTime | When the assessment was documented | ||||
assessor | Σ | 0..1 | Reference(Practitioner | PractitionerRole) | The clinician performing the assessment | ||||
previous | 0..1 | Reference(ClinicalImpression) | Reference to last assessment | |||||
problem | Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state | ||||
investigation | 0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | 1..1 | CodeableConcept | A 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..* | uri | Clinical Protocol followed | |||||
summary | S | 0..1 | string | Summary of the assessment | ||||
finding | 0..* | BackboneElement | Possible or likely findings and diagnoses | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
itemCodeableConcept | 0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
itemReference | 0..1 | Reference(Condition | Observation | Media) | What was found | |||||
basis | 0..1 | string | Which investigations support finding | |||||
prognosisCodeableConcept | 0..* | CodeableConcept | Estimate 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..* | Annotation | Comments made about the ClinicalImpression | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
ClinicalImpression.language | preferred | CommonLanguages
| ||||
ClinicalImpression.status | required | Fixed Value: completed | ||||
ClinicalImpression.statusReason | example | |||||
ClinicalImpression.code | example | Fixed Value: LOINC code 75321-0("Clinical finding") | ||||
ClinicalImpression.investigation.code | example | InvestigationType | ||||
ClinicalImpression.finding.itemCodeableConcept | example | Condition/Problem/DiagnosisCodes | ||||
ClinicalImpression.prognosisCodeableConcept | example | ClinicalImpressionPrognosis |
This structure is derived from ClinicalImpression
Differential View
This structure is derived from ClinicalImpression
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
status | 1..1 | code | in-progress | completed | entered-in-error Fixed Value: completed | |
code | S | 1..1 | CodeableConcept | Kind of assessment performed Fixed Value: As shown |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75321-0 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical finding | |
subject | S | 1..1 | Reference(Patient | Group) | Patient or group assessed |
encounter | S | 0..1 | Reference(Encounter) | Encounter created as part of |
summary | S | 0..1 | string | Summary of the assessment |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!Σ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Fixed Value: completed |
code | SΣ | 1..1 | CodeableConcept | Kind 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 |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..0 | string | Unique id for inter-element referencing | |
extension | 0..0 | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
version | 0..0 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75321-0 | |
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical finding | |
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
text | 0..0 | string | Plain text representation of the concept | |
subject | SΣ | 1..1 | Reference(Patient | Group) | Patient or group assessed |
encounter | SΣ | 0..1 | Reference(Encounter) | Encounter created as part of |
summary | S | 0..1 | string | Summary of the assessment |
Documentation for this format |
Path | Conformance | ValueSet / Code |
ClinicalImpression.status | required | Fixed Value: completed |
ClinicalImpression.code | example | Fixed Value: LOINC code 75321-0("Clinical finding") |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ClinicalImpression | 0..* | ClinicalImpression | A clinical assessment performed when planning treatments and management strategies for a patient | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier | ||||
status | ?!Σ | 1..1 | code | in-progress | completed | entered-in-error Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression. Fixed Value: completed | ||||
statusReason | 0..1 | CodeableConcept | Reason for current status Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression. | |||||
code | SΣ | 1..1 | CodeableConcept | Kind 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 | ||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
id | 0..0 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | Extension | Additional content defined by implementations | |||||
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
version | 0..0 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 75321-0 | |||||
display | 1..1 | string | Representation defined by the system Fixed Value: Clinical finding | |||||
userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |||||
text | 0..0 | string | Plain text representation of the concept | |||||
description | Σ | 0..1 | string | Why/how the assessment was performed | ||||
subject | SΣ | 1..1 | Reference(Patient | Group) | Patient or group assessed | ||||
encounter | SΣ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
effective[x] | Σ | 0..1 | Time of assessment | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
date | Σ | 0..1 | dateTime | When the assessment was documented | ||||
assessor | Σ | 0..1 | Reference(Practitioner | PractitionerRole) | The clinician performing the assessment | ||||
previous | 0..1 | Reference(ClinicalImpression) | Reference to last assessment | |||||
problem | Σ | 0..* | Reference(Condition | AllergyIntolerance) | Relevant impressions of patient state | ||||
investigation | 0..* | BackboneElement | One or more sets of investigations (signs, symptoms, etc.) | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | 1..1 | CodeableConcept | A 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..* | uri | Clinical Protocol followed | |||||
summary | S | 0..1 | string | Summary of the assessment | ||||
finding | 0..* | BackboneElement | Possible or likely findings and diagnoses | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
itemCodeableConcept | 0..1 | CodeableConcept | What was found Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis. | |||||
itemReference | 0..1 | Reference(Condition | Observation | Media) | What was found | |||||
basis | 0..1 | string | Which investigations support finding | |||||
prognosisCodeableConcept | 0..* | CodeableConcept | Estimate 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..* | Annotation | Comments made about the ClinicalImpression | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
ClinicalImpression.language | preferred | CommonLanguages
| ||||
ClinicalImpression.status | required | Fixed Value: completed | ||||
ClinicalImpression.statusReason | example | |||||
ClinicalImpression.code | example | Fixed Value: LOINC code 75321-0("Clinical finding") | ||||
ClinicalImpression.investigation.code | example | InvestigationType | ||||
ClinicalImpression.finding.itemCodeableConcept | example | Condition/Problem/DiagnosisCodes | ||||
ClinicalImpression.prognosisCodeableConcept | example | ClinicalImpressionPrognosis |
This structure is derived from ClinicalImpression
Other representations of profile: CSV, Excel, Schematron