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Adding an Assessment

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 preparing the ClinicalImpression resource for a manual assessment performed by a clinician, it is important to add the following to the ClinicalImpression:

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

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

The sections below contain further cases for manual assessment.

Preparing an Assessment of a Measurement or Media

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

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

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

  • investigation.ehealth-clinicalimpression-mediaInvestigationItem which shall be set to both a versioned and version-less (see info-box below) reference to the Media, when a Media is assessed

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

Preparing an Assessment of a Clinical Impression

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

  • previous which shall be set as a reference to the ClinicalImpression being assessed

  • investigation.item or investigation.ehealth-clinicalimpression-mediaInvestigationItem which shall be set to the same value as in the previous ClinincalImpression

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