MII IG Kerndatensatz-Modul Seltene Erkrankungen
2027.0.0-ballot - Germany

This page is part of the MII Implementation Guide Seltene Erkrankungen (v2027.0.0-ballot: 2027 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Ressourcenprofil: MII Profile SE Clinical Impression

Offizielle URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/StructureDefinition/mii-pr-seltene-clinical-impression Version: 2027.0.0-ballot
Active Stand: 2026-09-14 Maschinenlesbarer Name: MII_PR_Seltene_ClinicalImpression

Profile for clinical impressions in the context of rare diseases. This profile captures clinical assessments and suspected diagnoses based on phenotypic findings and symptoms.

Dieses Profil beschreibt die klinische Bewertung und Dokumentation interdisziplinärer Untersuchungen im Rahmen der Diagnostik seltener Erkrankungen. Es ermöglicht die strukturierte Erfassung klinischer Eindrücke, Befunde und Behandlungsempfehlungen.

Strukturierung der klinischen Bewertung

Die ClinicalImpression nutzt drei Hauptelemente zur Strukturierung der klinischen Bewertung:

Problem (problem)

Dokumentiert die identifizierten Gesundheitsprobleme oder Diagnosen:

  • Bestätigte Diagnosen (ICD-10-GM, ORPHAcodes)
  • Verdachtsdiagnosen
  • Symptom-Conditions (symptomatische Zustände)
  • Beispiel: "Verdacht auf Osteogenesis imperfecta" oder "Bestätigte Von-Willebrand-Erkrankung"

Investigation (investigation)

Erfasst durchgeführte oder geplante Untersuchungen zur Abklärung:

  • Gruppierung zusammengehöriger Diagnostik
  • Labor-Panels (z.B. Gerinnungsdiagnostik)
  • Bildgebende Verfahren
  • Genetische Tests
  • Beispiel: Investigation mit Code "Basisdiagnostik" enthält Referenzen auf CBC, PTT, Blutungszeit

Finding (finding)

Dokumentiert konkrete Befunde und Beobachtungen:

  • HPO-kodierte phänotypische Merkmale
  • Auffällige Laborwerte
  • Bildgebungsbefunde
  • Klinische Beobachtungen
  • Beispiel: "Erhöhte PTT (409675001)", "Bruising susceptibility (HP:0000978)"

Verwendungsbeispiel

ClinicalImpression (Erstvorstellung)
├── problem: Verdacht auf Von-Willebrand-Syndrom
├── investigation[0]: 
│   ├── code: "Gerinnungsdiagnostik"
│   └── item: [PTT-Messung, vWF-Aktivität, Blutungszeit]
└── finding[0]: Nasenbluten (R04.0)
└── finding[1]: Hämatom-Neigung (HP:0000978)
└── finding[2]: PTT verlängert (409675001)

Suchparameter sind modulweit im CapabilityStatement deklariert — dort maschinenlesbar und vollständig, statt je Profil von Hand wiederholt.

Beispielinstanzen sind auf der Profilseite im Abschnitt „Examples" verlinkt.

Usages:

You can also check for usages in the FHIR IG Statistics

Formale Ansichten des Profilinhalts

Beschreibung von Profilen, Differentials, Snapshots und deren Repräsentationen.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id SΣ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... identifier SΣ 0..* Identifier Business identifier
... status ?!SΣ 1..1 code Status der klinischen Beurteilung
Binding: ClinicalImpressionStatus (required)
... code SΣ 0..1 CodeableConcept Art der klinischen Beurteilung
Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
... description SΣ 0..1 string Zusammenfassung der klinischen Beurteilung
... subject SΣ 1..1 Reference(Patient) Patient, der beurteilt wird
... encounter SΣ 0..1 Reference(Encounter) Encounter created as part of
... Slices for effective[x] SΣ 0..1 Zeitpunkt der Beurteilung
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime Σ 0..1 dateTime Time of assessment
.... effective[x]:effectivePeriod Σ 0..1 Period Time of assessment
..... start ΣC 0..1 dateTime Starting time with inclusive boundary
..... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... date SΣ 0..1 dateTime Wann die Beurteilung dokumentiert wurde
... problem SΣ 0..* Reference(Condition | AllergyIntolerance) Relevante Probleme/Erkrankungen
... investigation S 0..* BackboneElement Eine oder mehrere Untersuchungsserien
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 CodeableConcept Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde
Binding: InvestigationType (example): A name/code for a set of investigations.
.... item 0..* Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment) Unters
... summary S 0..1 string Zusammenfassung der klinischen Beurteilung
... finding S 0..* BackboneElement Klinische Befunde der Untersuchung
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1 CodeableConcept Klinischer Befund
Binding: HPO Phenotypic Observation Codes (extensible)
.... itemReference 0..1 Reference(Condition | Observation) Referenz auf klinischen Befund
.... basis 0..1 string Grundlage für den Befund
... supportingInfo S 0..* Reference(Observation | Condition | DiagnosticReport | DocumentReference) Unterstützende Informationen
... note S 0..* Annotation Zusätzliche Anmerkungen

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.status Base required Clinical Impression Status 📦4.0.1 FHIR Std.
ClinicalImpression.code Base example Not State Unknown
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base extensible HPO Phenotypic Observation Codes 📦2027.0.0-ballot This IG

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Diese Struktur ist abgeleitet von ClinicalImpression

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id S 0..1 id Logical id of this artifact
... meta S 0..1 Meta Metadata about the resource
... identifier S 0..* Identifier Business identifier
... code S 0..1 CodeableConcept Art der klinischen Beurteilung
... description S 0..1 string Zusammenfassung der klinischen Beurteilung
... subject S 1..1 Reference(Patient) Patient, der beurteilt wird
... encounter S 0..1 Reference(Encounter) Encounter created as part of
... Slices for effective[x] S 0..1 dateTime, Period Zeitpunkt der Beurteilung
Slice: Unordered, Open by type:$this
.... effective[x]:effectiveDateTime 0..1 dateTime Time of assessment
.... effective[x]:effectivePeriod 0..1 Period Time of assessment
..... start 0..1 dateTime Starting time with inclusive boundary
..... end 0..1 dateTime End time with inclusive boundary, if not ongoing
... date S 0..1 dateTime Wann die Beurteilung dokumentiert wurde
... problem S 0..* Reference(Condition | AllergyIntolerance) Relevante Probleme/Erkrankungen
... investigation S 0..* BackboneElement Eine oder mehrere Untersuchungsserien
.... code S 1..1 CodeableConcept Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde
.... item 0..* Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment) Unters
... summary S 0..1 string Zusammenfassung der klinischen Beurteilung
... finding S 0..* BackboneElement Klinische Befunde der Untersuchung
.... itemCodeableConcept 0..1 CodeableConcept Klinischer Befund
Binding: HPO Phenotypic Observation Codes (extensible)
.... itemReference 0..1 Reference(Condition | Observation) Referenz auf klinischen Befund
.... basis 0..1 string Grundlage für den Befund
... supportingInfo S 0..* Reference(Observation | Condition | DiagnosticReport | DocumentReference) Unterstützende Informationen
... note S 0..* Annotation Zusätzliche Anmerkungen

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClinicalImpression.status Base required Clinical Impression Status 📦4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base extensible HPO Phenotypic Observation Codes 📦2027.0.0-ballot This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id SΣ 0..1 id Logical id of this artifact
... meta SΣ 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.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Business identifier
... status ?!SΣ 1..1 code Status der klinischen Beurteilung
Binding: ClinicalImpressionStatus (required)
... statusReason 0..1 CodeableConcept Reason for current status
Binding Description: (example): Codes identifying the reason for the current state of a clinical impression.
... code SΣ 0..1 CodeableConcept Art der klinischen Beurteilung
Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
... description SΣ 0..1 string Zusammenfassung der klinischen Beurteilung
... subject SΣ 1..1 Reference(Patient) Patient, der beurteilt wird
... encounter SΣ 0..1 Reference(Encounter) Encounter created as part of
... Slices for effective[x] SΣ 0..1 Zeitpunkt der Beurteilung
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime Σ 0..1 dateTime Time of assessment
.... effective[x]:effectivePeriod Σ 0..1 Period Time of assessment
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... start ΣC 0..1 dateTime Starting time with inclusive boundary
..... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... date SΣ 0..1 dateTime Wann die Beurteilung dokumentiert wurde
... assessor Σ 0..1 Reference(Practitioner | PractitionerRole) The clinician performing the assessment
... previous 0..1 Reference(ClinicalImpression) Reference to last assessment
... problem SΣ 0..* Reference(Condition | AllergyIntolerance) Relevante Probleme/Erkrankungen
... investigation S 0..* BackboneElement Eine oder mehrere Untersuchungsserien
.... 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 S 1..1 CodeableConcept Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde
Binding: InvestigationType (example): A name/code for a set of investigations.
.... item 0..* Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment) Unters
... protocol 0..* uri Clinical Protocol followed
... summary S 0..1 string Zusammenfassung der klinischen Beurteilung
... finding S 0..* BackboneElement Klinische Befunde der Untersuchung
.... 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 Klinischer Befund
Binding: HPO Phenotypic Observation Codes (extensible)
.... itemReference 0..1 Reference(Condition | Observation) Referenz auf klinischen Befund
.... basis 0..1 string Grundlage für den Befund
... prognosisCodeableConcept 0..* CodeableConcept Estimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
... prognosisReference 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome
... supportingInfo S 0..* Reference(Observation | Condition | DiagnosticReport | DocumentReference) Unterstützende Informationen
... note S 0..* Annotation Zusätzliche Anmerkungen

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClinicalImpression.status Base required Clinical Impression Status 📦4.0.1 FHIR Std.
ClinicalImpression.statusReason Base example Not State Unknown
ClinicalImpression.code Base example Not State Unknown
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base extensible HPO Phenotypic Observation Codes 📦2027.0.0-ballot This IG
ClinicalImpression.prognosisCodeableConcept Base example Clinical Impression Prognosis 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Diese Struktur ist abgeleitet von ClinicalImpression

Summary

Must-Support: 17 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of ClinicalImpression.effective[x]

Schlüsselelemente-Ansicht

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id SΣ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... identifier SΣ 0..* Identifier Business identifier
... status ?!SΣ 1..1 code Status der klinischen Beurteilung
Binding: ClinicalImpressionStatus (required)
... code SΣ 0..1 CodeableConcept Art der klinischen Beurteilung
Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
... description SΣ 0..1 string Zusammenfassung der klinischen Beurteilung
... subject SΣ 1..1 Reference(Patient) Patient, der beurteilt wird
... encounter SΣ 0..1 Reference(Encounter) Encounter created as part of
... Slices for effective[x] SΣ 0..1 Zeitpunkt der Beurteilung
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime Σ 0..1 dateTime Time of assessment
.... effective[x]:effectivePeriod Σ 0..1 Period Time of assessment
..... start ΣC 0..1 dateTime Starting time with inclusive boundary
..... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... date SΣ 0..1 dateTime Wann die Beurteilung dokumentiert wurde
... problem SΣ 0..* Reference(Condition | AllergyIntolerance) Relevante Probleme/Erkrankungen
... investigation S 0..* BackboneElement Eine oder mehrere Untersuchungsserien
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 CodeableConcept Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde
Binding: InvestigationType (example): A name/code for a set of investigations.
.... item 0..* Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment) Unters
... summary S 0..1 string Zusammenfassung der klinischen Beurteilung
... finding S 0..* BackboneElement Klinische Befunde der Untersuchung
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1 CodeableConcept Klinischer Befund
Binding: HPO Phenotypic Observation Codes (extensible)
.... itemReference 0..1 Reference(Condition | Observation) Referenz auf klinischen Befund
.... basis 0..1 string Grundlage für den Befund
... supportingInfo S 0..* Reference(Observation | Condition | DiagnosticReport | DocumentReference) Unterstützende Informationen
... note S 0..* Annotation Zusätzliche Anmerkungen

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.status Base required Clinical Impression Status 📦4.0.1 FHIR Std.
ClinicalImpression.code Base example Not State Unknown
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base extensible HPO Phenotypic Observation Codes 📦2027.0.0-ballot This IG

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential-Ansicht

Diese Struktur ist abgeleitet von ClinicalImpression

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id S 0..1 id Logical id of this artifact
... meta S 0..1 Meta Metadata about the resource
... identifier S 0..* Identifier Business identifier
... code S 0..1 CodeableConcept Art der klinischen Beurteilung
... description S 0..1 string Zusammenfassung der klinischen Beurteilung
... subject S 1..1 Reference(Patient) Patient, der beurteilt wird
... encounter S 0..1 Reference(Encounter) Encounter created as part of
... Slices for effective[x] S 0..1 dateTime, Period Zeitpunkt der Beurteilung
Slice: Unordered, Open by type:$this
.... effective[x]:effectiveDateTime 0..1 dateTime Time of assessment
.... effective[x]:effectivePeriod 0..1 Period Time of assessment
..... start 0..1 dateTime Starting time with inclusive boundary
..... end 0..1 dateTime End time with inclusive boundary, if not ongoing
... date S 0..1 dateTime Wann die Beurteilung dokumentiert wurde
... problem S 0..* Reference(Condition | AllergyIntolerance) Relevante Probleme/Erkrankungen
... investigation S 0..* BackboneElement Eine oder mehrere Untersuchungsserien
.... code S 1..1 CodeableConcept Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde
.... item 0..* Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment) Unters
... summary S 0..1 string Zusammenfassung der klinischen Beurteilung
... finding S 0..* BackboneElement Klinische Befunde der Untersuchung
.... itemCodeableConcept 0..1 CodeableConcept Klinischer Befund
Binding: HPO Phenotypic Observation Codes (extensible)
.... itemReference 0..1 Reference(Condition | Observation) Referenz auf klinischen Befund
.... basis 0..1 string Grundlage für den Befund
... supportingInfo S 0..* Reference(Observation | Condition | DiagnosticReport | DocumentReference) Unterstützende Informationen
... note S 0..* Annotation Zusätzliche Anmerkungen

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClinicalImpression.status Base required Clinical Impression Status 📦4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base extensible HPO Phenotypic Observation Codes 📦2027.0.0-ballot This IG

Snapshot-AnsichtView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClinicalImpression 0..* ClinicalImpression A clinical assessment performed when planning treatments and management strategies for a patient
... id SΣ 0..1 id Logical id of this artifact
... meta SΣ 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.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Business identifier
... status ?!SΣ 1..1 code Status der klinischen Beurteilung
Binding: ClinicalImpressionStatus (required)
... statusReason 0..1 CodeableConcept Reason for current status
Binding Description: (example): Codes identifying the reason for the current state of a clinical impression.
... code SΣ 0..1 CodeableConcept Art der klinischen Beurteilung
Binding Description: (example): Identifies categories of clinical impressions. This is a place-holder only. It may be removed.
... description SΣ 0..1 string Zusammenfassung der klinischen Beurteilung
... subject SΣ 1..1 Reference(Patient) Patient, der beurteilt wird
... encounter SΣ 0..1 Reference(Encounter) Encounter created as part of
... Slices for effective[x] SΣ 0..1 Zeitpunkt der Beurteilung
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime Σ 0..1 dateTime Time of assessment
.... effective[x]:effectivePeriod Σ 0..1 Period Time of assessment
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... start ΣC 0..1 dateTime Starting time with inclusive boundary
..... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... date SΣ 0..1 dateTime Wann die Beurteilung dokumentiert wurde
... assessor Σ 0..1 Reference(Practitioner | PractitionerRole) The clinician performing the assessment
... previous 0..1 Reference(ClinicalImpression) Reference to last assessment
... problem SΣ 0..* Reference(Condition | AllergyIntolerance) Relevante Probleme/Erkrankungen
... investigation S 0..* BackboneElement Eine oder mehrere Untersuchungsserien
.... 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 S 1..1 CodeableConcept Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde
Binding: InvestigationType (example): A name/code for a set of investigations.
.... item 0..* Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment) Unters
... protocol 0..* uri Clinical Protocol followed
... summary S 0..1 string Zusammenfassung der klinischen Beurteilung
... finding S 0..* BackboneElement Klinische Befunde der Untersuchung
.... 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 Klinischer Befund
Binding: HPO Phenotypic Observation Codes (extensible)
.... itemReference 0..1 Reference(Condition | Observation) Referenz auf klinischen Befund
.... basis 0..1 string Grundlage für den Befund
... prognosisCodeableConcept 0..* CodeableConcept Estimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.
... prognosisReference 0..* Reference(RiskAssessment) RiskAssessment expressing likely outcome
... supportingInfo S 0..* Reference(Observation | Condition | DiagnosticReport | DocumentReference) Unterstützende Informationen
... note S 0..* Annotation Zusätzliche Anmerkungen

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClinicalImpression.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClinicalImpression.status Base required Clinical Impression Status 📦4.0.1 FHIR Std.
ClinicalImpression.statusReason Base example Not State Unknown
ClinicalImpression.code Base example Not State Unknown
ClinicalImpression.investigation.​code Base example Investigation Type 📍4.0.1 FHIR Std.
ClinicalImpression.finding.​itemCodeableConcept Base extensible HPO Phenotypic Observation Codes 📦2027.0.0-ballot This IG
ClinicalImpression.prognosisCodeableConcept Base example Clinical Impression Prognosis 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClinicalImpression If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClinicalImpression If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClinicalImpression If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClinicalImpression A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Diese Struktur ist abgeleitet von ClinicalImpression

Summary

Must-Support: 17 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of ClinicalImpression.effective[x]

 

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