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  1. FHIR Specification Feedback
  2. FHIR-18859

Definition/description at odds with what clinical impression is - STU #208

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    Details

    • Type: Change Request
    • Status: Triaged (View Workflow)
    • Priority: Medium
    • Resolution: Unresolved
    • Specification:
      FHIR Core (FHIR)
    • Raised in Version:
      STU3
    • Work Group:
      Patient Care
    • Related Artifact(s):
      ClinicalImpression
    • Resolution Description:
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      Not Persuasive only due to the tracker being deferred (post R4)

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      Not Persuasive only due to the tracker being deferred (post R4)
    • Change Category:
      Clarification

      Description

      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

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              Assignee:
              Unassigned Unassigned
              Reporter:
              chuscmi Stephen Chu
              Watchers:
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                Dates

                Created:
                Updated: