Clinicalassessment-example.xml

Example of clinicalassessment (id = "example")

Raw XML

<ClinicalAssessment xmlns="http://hl7.org/fhir">
  <id value="example"/>
  <patient>
    <reference value="Patient/example"/>
  </patient>  
  <assessor>
    <reference value="Practitioner/example"/>
  </assessor>
  <date value="2014-12-06T22:33:00+11:00"/>
  <description value="This 26 yo male patient is brought into ER by ambulance after being involved in a motor
   vehicle accident"/>
  <problem>
    <display value="MVA"/> <!--   todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event)
       -->
  </problem>
  <investigations>
    <code>
      <text value="Initial Examination"/>
    </code>
    <!--   todo: turn all of these into observations   -->
    <item>
      <display value="deep laceration of the scalp (left temporo-occipital)"/>
    </item>
    <item>
      <display value="decreased level of consciousness"/>
    </item>
    <item>
      <display value="disoriented to time and place"/>
    </item>
    <item>
      <display value="restless"/>
    </item>
  </investigations>
  <summary value="provisional diagnoses of laceration of head and traumatic brain injury (TBI)"/>
  <diagnosis>
    <item>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-9"/>
        <code value="850.0"/>
      </coding>
    </item>
  </diagnosis>
  <plan>
    <!--   in real life, this would be a reference   -->
    <display value="hospital standard closed head injury management protocol "/>
  </plan>
</ClinicalAssessment>