Clinicalimpression-example.json

Example of clinicalimpression

{
  "resourceType": "ClinicalImpression",
  "id": "example",
  "text": {
    "status": "generated",
    "div": "<div><p><b>Generated Narrative with Details</b></p><p><b>id</b>: example</p><p><b>patient</b>: <a>Patient/example</a></p><p><b>assessor</b>: <a>Practitioner/example</a></p><p><b>status</b>: completed</p><p><b>date</b>: 06/12/2014 10:33:00 PM</p><p><b>description</b>: This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident</p><p><b>problem</b>: MVA</p><h3>Investigations</h3><table><tr><td>-</td><td><b>Code</b></td><td><b>Item</b></td></tr><tr><td>*</td><td>Initial Examination <span>(Details )</span></td><td>deep laceration of the scalp (left temporo-occipital)</td></tr></table><p><b>summary</b>: provisional diagnoses of laceration of head and traumatic brain injury (TBI)</p><h3>Findings</h3><table><tr><td>-</td><td><b>Item</b></td></tr><tr><td>*</td><td>?? <span>(Details : {ICD-9 code '850.0' = '??)</span></td></tr></table><p><b>plan</b>: hospital standard closed head injury management protocol </p></div>"
  },
  "patient": {
    "reference": "Patient/example"
  },
  "assessor": {
    "reference": "Practitioner/example"
  },
  "status": "completed",
  "date": "2014-12-06T22:33:00+11:00",
  "description": "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident",
  "problem": [
    {
      "fhir_comments": [
        "   todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event)   "
      ],
      "display": "MVA"
    }
  ],
  "investigations": [
    {
      "code": {
        "text": "Initial Examination"
      },
      "item": [
        {
          "fhir_comments": [
            "   todo: turn all of these into observations   "
          ],
          "display": "deep laceration of the scalp (left temporo-occipital)"
        },
        {
          "display": "decreased level of consciousness"
        },
        {
          "display": "disoriented to time and place"
        },
        {
          "display": "restless"
        }
      ]
    }
  ],
  "summary": "provisional diagnoses of laceration of head and traumatic brain injury (TBI)",
  "finding": [
    {
      "item": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/icd-9",
            "code": "850.0"
          }
        ]
      }
    }
  ],
  "plan": [
    {
      "display": "hospital standard closed head injury management protocol ",
      "_display": {
        "fhir_comments": [
          "   in real life, this would be a reference   "
        ]
      }
    }
  ]
}