Clinicalassessment-example.json

Example of clinicalassessment

{
  "resourceType": "ClinicalAssessment",
  "id": "example",
  "patient": {
    "reference": "Patient/example"
  },
  "assessor": {
    "reference": "Practitioner/example"
  },
  "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": [
    {
      "display": "MVA"
    }
  ],
  "investigations": [
    {
      "code": {
        "text": "Initial Examination"
      },
      "item": [
        {
          "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)",
  "diagnosis": [
    {
      "item": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/icd-9",
            "code": "850.0"
          }
        ]
      }
    }
  ],
  "plan": {
    "display": "hospital standard closed head injury management protocol "
  }
}