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Type:
Change Request
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Resolution: Unresolved
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Priority:
Medium
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FHIR Core (FHIR)
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STU3
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Patient Care
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ClinicalImpression
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Clarification
Existing Wording: Description = 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
Comment:
ClinicalImpression (resource) is described as: "a record of a clinical assessment performed …"
This description/definition is at odd/semantically incompatible with the concept clinical impression
Clinical impression is a clinician's assertion/declaration of a patient's clinical state at the end of a clinical assessment
The structural definition of the ClinicalImpression as is represents a record of the clinical assessment performed and the assertion/declaration of the patient's clinical status based on the clinical assessment. As such, to lable it as ClinicalImpression is semantically inaccurate
Suggestion:
Either rename the resource to ClinicalAssessment and in the "Scope and Usage" section delcare that it should not be confused with assessment tool
Or
Redesign the resource to have the "Finding" (which should be renamed to "Impression" as the focal point, supported by evidences derived from the clinical assessment process
Summary:
Definition/description at odds with what clinical impression is
- is voted on by
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BALLOT-6626 Negative - Stephen Chu : 2018-Sep-FHIR R4
- Balloted