Existing Wording: ClinicalImpression

(clinicalimpression.html)

Contraindication

(contraindication.html)

QuestionnaireAnswers

(questionnaireanswers.html)

CarePlan (careplan.html)

Goal (goal.html)

Comment:

not at all clear which of these are master files( Knowledge bases) versus patient specific data The distinction should be asserted in the description. The medications resource makes it clear that it is a knowledge base, not patient specific entity. (Labs and tests and nursing orders need the same kind of master file. (And don't think its a data element anymore than medications are)

Contra-indications strike me as something that is also a master file and applies in general not something that is specific to the patient.

needs clarification

Clinical impression as a resource is problematic and should be removed. Its only clear use is as one section of a SOAP problem oriented note. It is not an independent entity. Any more than the 3-4 parts of radiologist reports, Reason for study, findings, impression_ are . Further lab tests routinely include an summative element that is labeled an impression or interpretation, and it is just another observations. If readers of this standard believe they all have to be impression resources it will add complexity with no utility. ~~

Risk assement is a new invention in the sense of being a separate thing. Suspect it does not deserve its own separate resource and will create lots of work for people trying to decide what goes where. Some lab test , e.g. prenatal screening reports values that are literally risk as does the framing ham risk equation. There is no reason to distinguish these structurally from bread and butter observations, they could be culled out when/if needed by looking at the master file.