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Assessment

The SHR Assessment domain contains definitions used to capture judgments, medical opinions, clinical impressions, diagnoses, and inferences drawn from evidence.

Assessment [Entry]

A conclusion (tentative or final) resulting from synthesis of evidence (one or more observations). An Assessment is a judgment rendered at a point in time. A diagnosis is a type of Assessment that can lead to creation of a Condition. C0220825

Based On Action

Category from AssessmentTypeVS (if covered) 0 or more A categorization of the action according its type, often a code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This can be used for searching, sorting and display purposes.
Status must be from http://hl7.org/fhir/ValueSet/clinical-impression-status required The position of affairs at a particular time
AssessmentFocus 0 or more The topic or target of an analysis or assessment. For example, if the question involves the progression of the subject's diabetes, then the FocalCondition would be diabetes. If the investigation involves the toxicity of chemotherapy regimen, the focus would be that regimen (currently the MedicationUse of the chemotherapy drug). If the analysis involves certain observations, they would be listed as the focus.
AssessmentResult 0 or more A statement of judgment or opinion, often the outcome, finding, or conclusion of the investigation or analysis.
Method optional The method of the observation, for example, the specific imaging technical or assessment vehicle.
ClinicallyRelevantTime optional The time or time period that the observation addresses. The clinically relevant time is not necessarily when the information is gathered or when a test is carried out, but for example, when a specimen was collected, or the time period referred to by the question. Use a TimePeriod for a measurement or specimen collection continued over a significant period of time (e.g. 24 hour Urine Sodium).
EvidenceQuality optional An estimate of the quality and/or quantity of the source information that supports the assessment.
Evidence 0 or more An observation that serves as evidence for some type of assessment.
Summary optional A shortened version of an item of information, containing only the main points.
SpecificType optional A code or description representing the concept represented by the instance at a specific level. For example, for a Condition, the concept is MTH#C0348080 (Condition) but the Value is the SpecificType, i.e. MTH#C0011849 (Diabetes Mellitus). For an observation, the SpecificType defines what is being observed, measured, or asked, as specifically as possible. The SpecificType should always align with the concept of the element, for example, a blood pressure observation can be coded as a sitting blood pressure or standing blood pressure, and may be from a different code system (e.g. LOINC versus MTH). In other cases, the SpecificType is the specific question being asked, or the specific goal being pursued.
NonOccurrenceModifier optional When true, indicates either that the event or action documented in the entry did not occur. For example, if immunization is not given, the NonOccurrenceModifier=true will indicate this. When applied to a recommendation, the modifier indicates the action mentioned in the topic should not take place. For example, a request to NOT elevate the head of a bed using the code for elevating the bed, and setting ProhibitedModifier to true. Other examples include do not ambulate, do not flush NG tube, do not take blood pressure on a certain arm, etc. If the SpecificType contains negation and ProhibitedModifier is true, that will reinforce the prohibition, and should not be interpreted as a double negative that equals a positive.
Reason 0 or more The justification for an action or non-action, conclusion, opinion, etc.
OccurrenceTime optional The point in time or span of time in which something happens.
Participant 0 or more A statement about an actor who did (or did not) participate in a certain task or activity. Unlike a HealthcareInvolvement which continues over period of time, the participant is associated with doing or not doing a specific task, such admitting a patient, performing a procedure, or taking a measurement.

AssessmentFocus

The topic or target of an analysis or assessment. For example, if the question involves the progression of the subject's diabetes, then the FocalCondition would be diabetes. If the investigation involves the toxicity of chemotherapy regimen, the focus would be that regimen (currently the MedicationUse of the chemotherapy drug). If the analysis involves certain observations, they would be listed as the focus.

Value:  Choice
         |  CodeableConcept required A set of codes drawn from different coding systems, representing the same concept.
         |  Procedure required An action that is or was performed on a patient. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy.
         |  Observation required An Observation represents evidence, both subjective and objective. Observation includes any information about a subject that results from an act of observing, measuring, or evaluation. The focus of an observation can include the subject's behavior, physiological state, health state, functional status, environment, exposures to substances, etc. An Observation contains information about the act of observing or measuring, and the result of the observation. The method of observing can vary widely, from questioning, physical examination, formal assessment vehicles, laboratory tests, imaging procedures, etc. Patient-reported information is also considered an observation, where subject and observer are the same individual.
         |  Condition required A representation of a disorder, abnormality, problem, injury, complaint, risk, functionality, concern, illness, disease, ailment, sickness, affliction, upset, difficulty, disorder, symptom, worry, or trouble. Condition can be used to track a problem or a risk over a period of time. By virtue of its continuity over time, Condition is different from an Observation or Assessment; Observations represents evidence, and an Assessment is a judgment based on evidence and rendered at a point in time. Diagnosis is a type of Assessment that can lead to creation of a Condition (as can an assessment of risk). The two relate because observations can lead to conclusion that a Condition exists. A statement that a certain condition does not exist should be an assessment. Not all conditions are problems, but all problems are (in some sense) conditions.
         |  AllergyIntolerance required A statement pertaining to an individual's allergies and intolerances to substances or classes of substances. Can be used to record that a substance does not pose an elevated risk to the subject (AssertionNegationModifier = true).

AssessmentResult

A statement of judgment or opinion, often the outcome, finding, or conclusion of the investigation or analysis.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.
AssertionNegationModifier optional When true, this modifier indicates that the associated observation, assessment, or finding is false, the condition is absent. For example, if the assessment is 'allergy to peanuts' and the AssertionNegationModifier is true, it means the subject does not have an allergy to peanuts.
Certainty optional The degree of confidence in a conclusion or assertion.

EvidenceQuality

An estimate of the quality and/or quantity of the source information that supports the assessment.

Value:  CodeableConcept must be from EvidenceQualityVS A set of codes drawn from different coding systems, representing the same concept.