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Assessments can be made on measurements and clinical impressions through ClinicalImpression Create. As described in ClinicalImpression, it has multiple uses in the eHealth Infrastructure for both automatic and manual assessment.
For When preparing the ClinicalImpression resource for a manual assessment performed by a clinician, it is important to add the following to the ClinicalImpression:
assessorwhich shall be set as a reference to the clinician's Practitionerehealth-clinicalimpression-decisioncan be set to a decision if applicableinvestigation.itemshall be set to both a versioned and version-less (see info-box below) reference to each measurement
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Versioned and version-less referencing from ClinicalImpression The versioned reference is required to eliminate ambiguity as to what content the ClinicalImpression has assessment for. An example versioned reference is:
The version number to use is taken from the resource’s .meta/versionId. Note that <base> is a substitution and that, in reality, it would reflect the eHealth environment in use. The version-less reference is required to enable searching for the resource reference without having to know which version is referenced. An example version-less reference is:
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The sections below contain further cases for manual assessment that expand on this.
Preparing an
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assessment of a measurement (Observation, QuestionnaireResponse or Media)
Add the following to the ClinicalImpression resource being prepared as described above:
ehealth-clinicalimpression-careplanwhich shall be set as a reference to the CarePlan that references the measurement’s ServiceRequestinvestigation.itemwhich shall be set to both a versioned and version-less (see info-box below) reference to the measurement
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Versioned and version-less referencing from ClinicalImpression The versioned reference is required to eliminate ambiguity as to what content the ClinicalImpression has assessment for. An example versioned reference is:
The version number to use is taken from the resource’s .meta/versionId. Note that <base> is a substitution and that, in reality, it would reflect the eHealth environment in use. The version-less reference is required to enable searching for the resource reference without having to know which version is referenced. An example version-less reference is:
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Preparing an
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assessment of a
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clinical impression
This is the scenario where a ClinicalImpression already exists. Either created by the infrastructure as a result of automated triaging or created earlier by a clinician. Further information can be added to the existing ClinicalImpression by creating a new ClinicalImpression that references the existing ClinicalImpression as previous
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previouswhich shall be set as a reference to the ClinicalImpression being assessedinvestigation.itemwhich shall be set to the same value values as in thepreviousClinincalImpressionClinicalImpression.investigation.itemin the ClinicalImpression referenced asprevious
Approving measurements for sharing
A ClinicalImpression can be used to approve one or more measurements for sharing. This is done by using the decision code: Add the following to the ClinicalImpression resource being prepared as described above:
ehealth-clinicalimpression-decisionshall be set toapproved-for-sharing
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If measurements reference each other, it is recommended to approve them using a single ClinicalImpression with multiple |