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. This resource is called "ClinicalImpression" rather than "ClinicalAssessment" to avoid confusion with the recording of assessment tools such as Apgar score.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Уникальный идентификатор элемента в ресурсе (для внутренних ссылок). Это может быть любое строковое значение, не содержащее пробелов.

An Extension

Идентификатор конкретной версии, который отображается в части URL, относящейся к версии. Это значение изменяется при создании, обновлении или удалении ресурса.

Сервер присваивает это значение и игнорирует то, что указывает клиент, за исключением случая, когда сервер устанавливает целостность версии при обновлении/удалении.

Когда ресурс менялся в последний раз - например, когда изменилась версия.

Этот элемент обычно опускается в экземплярах, отправляемых с помощью PUT или POST. Вместо этого он заполняется в экземпляре ответа и при получении информации с помощью GET. Это значение задается менеджером сервера / ресурсов; то, что предоставляет клиент, не имеет значения. Это эквивалентно последнему изменению HTTP и должно иметь такое же значение при взаимодействии read.

uri, который идентифицирует систему-источник ресурса. Он предоставляет минимальный объем информации о [Provenance] (provenance.html#), которую можно использовать для отслеживания или определения источника информации на ресурсе. Источник может идентифицировать другой сервер FHIR, документ, сообщение, базу данных и т.д.

Точное использование источника (и возможное подразумеваемое Provenance.entity.role и agent.role) остается на усмотрение разработчика. Допускается только один указанный источник; для получения дополнительной информации о происхождении следует использовать полный источник. Источник может соответствовать Provenance.entity.what[x] или Provenance.agent.who[x], хотя это может быть и более общая или абстрактная ссылка.

Этот элемент может использоваться для указания текущего главного источника ресурса, имеющего канонический URL-адрес, если ресурс больше не размещен по каноническому URL-адресу.

Список профилей (ссылок на StructureDefinition ресурсы), которым, как утверждается, соответствует этот ресурс. URL-адрес является ссылкой на StructureDefinition.url.

Сервер и/или другая инфраструктура политики должны определять, проверяются ли и/или обновляются ли эти утверждения с течением времени. Список URL-адресов профиля представляет собой набор.

Метки безопасности, применяемые к данному ресурсу. Эти метки связывают определенные ресурсы с общей политикой безопасности и инфраструктурой.

Метки безопасности могут быть обновлены без изменения указанной версии ресурса. Список меток безопасности представляет собой набор. Уникальность основана на системе/коде, а версия и отображение игнорируются.

Защитные этикетки из системы классификации конфиденциальности и безопасности в сфере здравоохранения.

Теги, применяемые к этому ресурсу. Теги предназначены для идентификации ресурсов и соотнесения их с процессами и документооборотом, и приложения не обязаны учитывать теги при интерпретации значения ресурса.

Теги могут быть обновлены без изменения заявленной версии ресурса. Список тегов представляет собой набор. Уникальность основана на системе/коде, а версия и отображение игнорируются.

Коды, представляющие различные типы тегов, обычно связанные с рабочим процессом; например, "Требуется проверка доктором Джонсом".

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of its narrative along with other profiles, value sets, etc.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Языковой тег IETF для человеческого языка

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have a narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags in their meta elements, but SHALL NOT have security labels.

An Extension

An Extension

Business identifiers assigned to this clinical impression by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

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.

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

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

Назначение этого идентификатора.

Приложения могут предполагать, что идентификатор является постоянным, если в нем явно не указано, что он временный.

Определяет назначение этого идентификатора, если оно известно.

Позволяет выбрать соответствующий идентификатор для конкретного контекста использования из набора идентификаторов.

Кодированный тип идентификатора, который может быть использован для определения того, какой идентификатор следует использовать для определенной цели..

Этот элемент относится только к общим категориям идентификаторов. Его не следует использовать для кодов, которые соответствуют 1..1 идентификатору.system. Некоторые идентификаторы могут быть разделены на несколько категорий из-за общего использования. Там, где система известна, тип не требуется, поскольку тип всегда является частью определения системы. Однако системам часто приходится обрабатывать идентификаторы, когда система неизвестна. Между типом и системой не существует соотношения 1:1, поскольку многие различные системы имеют один и тот же тип.

Кодированный тип идентификатора, который может быть использован для определения того, какой идентификатор следует использовать для определенной цели..

Позволяет пользователям использовать идентификаторы, когда система идентификации неизвестна.

Establishes the namespace for the value - that is, an absolute URL that describes a set values that are unique.

Identifier.system is always case sensitive.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the http://hl7.org/fhir/StructureDefinition/rendered-value). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Период времени, в течение которого идентификатор является/был действителен для использования.

Organization that issued/manages the identifier.

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a known RESTful URL) or by resolving the target of the reference.

Ресурс (или, для логических моделей, URI логической модели).

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

This element only allows for a single identifier. In the case where additional identifers are required, use the http://hl7.org/fhir/StructureDefinition/additionalIdentifier extension.

Plain text narrative that identifies the resource in addition to the resource reference.

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Identifies the workflow status of the assessment.

This element is labeled as a modifier because the status contains the code entered-in-error that marks the clinical impression as not currently valid.

The workflow state of a clinical impression.

Captures the reason for the current state of the ClinicalImpression.

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

Codes identifying the reason for the current state of a clinical impression.

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

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

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

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a known RESTful URL) or by resolving the target of the reference.

Ресурс (или, для логических моделей, URI логической модели).

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

This element only allows for a single identifier. In the case where additional identifers are required, use the http://hl7.org/fhir/StructureDefinition/additionalIdentifier extension.

Plain text narrative that identifies the resource in addition to the resource reference.

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

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

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.

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

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

Уникальный идентификатор элемента в ресурсе (для внутренних ссылок). Это может быть любое строковое значение, не содержащее пробелов.

An Extension

Начало периода действия.

Если нижний элемент отсутствует, это означает, что нижняя граница неизвестна.

Конец периода. Если дата окончания периода отсутствует, это означает, что на момент создания экземпляра не было известно или запланировано его окончание. Начало может быть в прошлом, а дата окончания - в будущем, что означает, что ожидается/планируется окончание периода в это время.

Конечное значение включает любую соответствующую дату/время. т.е. 2012-02-03T10:00:00 относится к периоду, конечное значение которого равно 2012-02-03.

Indicates when the documentation of the assessment was complete.

The clinician performing the assessment.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a known RESTful URL) or by resolving the target of the reference.

Ресурс (или, для логических моделей, URI логической модели).

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

This element only allows for a single identifier. In the case where additional identifers are required, use the http://hl7.org/fhir/StructureDefinition/additionalIdentifier extension.

Plain text narrative that identifies the resource in addition to the resource reference.

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

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.

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).

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

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

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.

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

A text summary of the investigations and the diagnosis.

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

Estimate of likely outcome.

Уникальный идентификатор элемента в ресурсе (для внутренних ссылок). Это может быть любое строковое значение, не содержащее пробелов.

An Extension

Ссылка на код в справочнике НСИ Терминология.

Коды могут быть определены очень небрежно в перечислениях или списках кодов, вплоть до очень формальных определений, таких как SNOMED CT - смотрите HL7 v3 Core Principles для получения дополнительной информации. Порядок кодировок не определен и НЕ должен использоваться для определения значения. Как правило, самое большее только одно из значений кодировки будет помечено как UserSelected = true.

Позволяет использовать альтернативные кодировки в рамках одной системы кодирования и переводить их в другие системы кодирования.

Уникальный идентификатор элемента в ресурсе (для внутренних ссылок). Это может быть любое строковое значение, не содержащее пробелов.

An Extension

Идентификация кодовой системы, которая определяет значение символа в коде.

URI может быть OID (urn:oid:...) или UUID (urn:uuid:...). Идентификаторы и UUID-коды ДОЛЖНЫ быть ссылками на реестр OID HL7. В противном случае URI должен быть взят из списка специальных URI, определенных FHIR в HL7, или он должен быть абсолютной ссылкой на какое-либо определение, которое четко и недвусмысленно устанавливает систему.

Необходимо четко указать источник определения символа.

Версия системы кодирования, которая использовалась при выборе этого кода. Обратите внимание, что для хорошо поддерживаемой системы кодирования не требуется указывать версию, поскольку значение кодов в разных версиях одинаково. Однако это не может быть гарантировано последовательно, и если нет гарантии, что значение будет непротиворечивым, следует заменить версию.

В тех случаях, когда терминология четко не определяет, какую строку следует использовать для идентификации версий системы кодирования, рекомендуется использовать в качестве даты версии дату (выраженную в формате даты FHIR), когда эта версия была официально опубликована.

Код.

Необходимо обратиться к определенному коду в системе.

Представление значения кода в системе в соответствии с правилами системы.

Необходимо иметь возможность передавать значение кода, понятное человеку, для читателей, которые не знакомы с системой.

Указывает на то, что данная кодировка была выбрана непосредственно пользователем - например, из списка доступных сущностей(кодов или отображений)..

Из множества альтернативных вариантов код, выбранный непосредственно, является наиболее подходящей отправной точкой для новых переводов. Существует некоторая неясность в отношении того, что именно подразумевается под "прямым выбором", и может потребоваться соглашение с торговым партнером, чтобы более полно разъяснить использование этого элемента и его последствия (коды или отображения).

Это было определено как критерий клинической безопасности - то, что именно эта пара система/код была выбрана явно, а не выведена системой на основе каких-либо правил или языковой обработки.

Представление концепции на человеческом языке, увиденное/выбранное/произнесенное пользователем, который ввел данные, и/или представляющее предполагаемый смысл пользователя.

Очень часто текст совпадает с отображаемым именем одной из кодировок.

Коды из терминологии не всегда отражают правильное значение со всеми нюансами, присущими человеку, который их использует, а иногда вообще не содержат соответствующего кода. В этих случаях используется текст, чтобы полностью передать значение источника.

RiskAssessment expressing likely outcome.

Information supporting the clinical impression, which can contain investigation results.

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

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