Reference to the patient who is the subject of this clinical assessment. This is the individual whose health status, problems, and prognosis are being evaluated by the healthcare practitioner.

Example: "patient-12345"

Reference to the healthcare encounter during which this assessment was performed. Links the assessment to the specific visit, admission, or consultation context in which the clinical evaluation occurred.

Example: "encounter-67890"

The current lifecycle status of this clinical assessment. Indicates whether the assessment is still being drafted, has been completed and finalized, or has been marked as entered in error and should be disregarded.

Values: draft, completed, entered-in-error

Example: "completed"

The date and time when this clinical assessment was made. Represents the specific moment when the practitioner formed their clinical impression based on available evidence and examination findings.

Example: "2024-03-15T14:30:00Z"

Reference to the healthcare practitioner who performed and documented this clinical assessment. The individual clinician responsible for the clinical judgment, interpretation of findings, and formulation of the impression.

Example: "practitioner-54321"

Array of coded problems, conditions, or diagnoses that are being assessed or considered in this clinical evaluation. Represents the health issues under investigation or requiring clinical judgment, typically coded using standard terminologies like ICD, SNOMED CT, or similar classification systems.

Example: "[{\"system\": \"http://snomed.info/sct\", \"code\": \"38341003\", \"display\": \"Hypertensive disorder\"}]"

List of investigations, tests, or diagnostic procedures that were performed or reviewed as part of this clinical assessment. May include laboratory tests, imaging studies, diagnostic procedures, or other clinical investigations that informed the practitioner's clinical impression.

Example: "[\"Complete blood count\", \"Chest X-ray\", \"ECG\"]"

Array of clinical protocols, guidelines, or pathways that were followed or referenced during this assessment. Documents the evidence-based frameworks or institutional policies that guided the clinical evaluation and decision-making process.

Example: "[\"NICE Hypertension Guidelines 2023\", \"Local Heart Failure Protocol\"]"

A comprehensive clinical summary that encapsulates the practitioner's overall assessment, clinical reasoning, and key conclusions. This narrative synthesizes the patient's presentation, investigation results, clinical findings, and the assessor's professional judgment into a coherent clinical picture.

Example: "Patient presents with uncontrolled hypertension despite dual therapy. Assessment reveals poorly controlled blood pressure with target organ involvement evidenced by left ventricular hypertrophy on ECG. Recommend treatment intensification and specialist cardiology review."

Array of key clinical findings identified during the assessment. Documents specific observations, signs, symptoms, or results that are clinically significant and contribute to the overall clinical impression and decision-making.

Example: "[\"Blood pressure 165/95 mmHg\", \"Left ventricular hypertrophy on ECG\", \"Retinal changes grade 2\"]"

A coded representation of the clinical prognosis or expected outcome for the patient based on the current assessment. Provides a standardized categorization of the anticipated disease course, recovery potential, or long-term outlook.

Values: excellent, good, fair, poor, guarded, terminal

Example: "good"

A narrative explanation of the prognosis that provides context, nuance, and clinical reasoning behind the prognostic assessment. Offers detailed insights into expected outcomes, potential complications, and factors influencing the prognosis.

Example: "With appropriate treatment intensification and lifestyle modifications, prognosis for blood pressure control is good. Regular monitoring required to prevent cardiovascular complications."

References to additional supporting information, documents, or resources that informed this clinical assessment. May include previous assessments, specialist reports, imaging results, or other clinical documentation that contributed to the current evaluation.

Example: "[\"Previous cardiology consultation 2023-12-10\", \"Echocardiogram report 2024-01-15\"]"

Array of recommended actions, interventions, or next steps resulting from this clinical assessment. Documents the care plan decisions, treatment modifications, referrals, or follow-up requirements based on the clinical impression.

Example: "[\"Add third antihypertensive agent\", \"Refer to cardiology\", \"Schedule follow-up in 2 weeks\"]"

Additional clinical notes, comments, or observations that provide supplementary context or information not captured in other structured fields. Used for documenting nuances, special circumstances, or ancillary information relevant to the assessment.

Example: "Patient reports good medication adherence. Family history of early cardiovascular disease noted. Patient counseled on lifestyle modifications and importance of blood pressure monitoring."

Computed flag indicating whether this clinical assessment has been completed and finalized. Returns true when the status is set to completed, signaling that the assessment is ready for clinical use and decision-making.

Example: "true"

Computed flag indicating whether a formal prognosis has been assigned to this assessment. Returns true when a prognosisCode has been set, signaling that the assessor has provided a prognostic evaluation of the patient's condition.

Example: "true"