Reason for no surgery: ClinicalImpression Resource

1

My system needs to record that a patient is not scheduled for surgery due to one of the following reasons: “Risk outweighs benefit”, “Stage IV disease”.

Is ClinicalImpression the most appropriate resource for this?

Thanks.

2

The simplest is to capture a Procedure record with a status of not-done with a statusReason indicating why. That way when you’re looking at the patient’s list of procedures, you’ll explicitly see the ones you might normally have expected to happen that didn’t happen and why. ClinicalImpression is more for the ‘assessment’ part of a SOAP, not to capture information about a specific procedure - though certainly that assessment might drive the reason to not have a procedure.

1 Like