Skip to main content

Assessments

Assessments (FHIR ClinicalImpression) capture a clinician’s overall evaluation of a patient — findings, diagnoses, investigations, prognosis, and clinical summary. They’re typically created during or after an encounter.

Create an Assessment

Assessment Code

Classify the type of assessment:

Status Reason

Explain why an assessment is still in progress:

Findings with Basis

Document which investigations support each finding:

Investigations

Group related clinical investigations:

Previous Assessment

Link to a prior assessment for longitudinal tracking:

Problem List

Reference the conditions being assessed:

Prognosis

Document the expected outcome:

Status Values

Update an Assessment

Search Assessments

Assessments vs Notes

Use assessments for structured clinical reasoning. Use notes for narrative documentation. They often complement each other — an encounter might have both a progress note and a clinical assessment.