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Excerpt

Technical description of how to add assessments on measurements and clinical impressions.

Table of Contents

Adding an Assessment

Assessments can be made on measurements and clinical impressions through ClinicalImpression Create.

As described in ClinicalImpression, it Clinical Impression has multiple uses in the eHealth Infrastructure for both automatic and manual assessment.

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  • assessor which shall be set as a reference to the clinician's Practitioner

  • ehealth-clinicalimpression-decision can be set to a decision if applicable

  • investigation.item shall be set to both a versioned and version-less (see info-box below) reference to each measurement

  • ehealth-clinicalimpression-careplan which shall be set as a reference to the CarePlan that references the measurement’s ServiceRequest

Note

The implication of setting ehealth-clinicalimpression-careplan is that all measurements referenced in investigation.item must have a ServiceRequest referenced from the same CarePlan.

Info

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:

  • https://<base>/fhir/QuestionnaireResponse/11052/_history/2

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:

  • https://<base>/fhir/QuestionnaireResponse/11052

...

Info

If measurements reference each other, it is recommended to approve them using a single ClinicalImpression with multiple investigation.item. This makes it possible to share them together when/if support for this is included in document sharing.

Approving Patient’s use of a view

A ClinicalImpression can be used to approve that a Patient may retrieve and project a measurement, typically a QuestionnaireResponse, through a view (see https://ehealth.sundhed.dk/fhir/StructureDefinition-ehealth-view.html ).

Add the following to the ClinicalImpression resource being prepared as described above:

  • investigation.ehealth-clinicalimpression-viewInvestigationItem shall reference the ehealth-view view