DSTU2 Ballot Source

This page is part of the FHIR Specification (v0.5.0: DSTU 2 Ballot 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Clinicalimpression-example

This is the narrative for the resource. See also the XML or JSON format.

Generated Narrative with Details

patient: Generated Summary: Extensions: todo; MRN = 12345 (USUAL); Peter James Chalmers (OFFICIAL), Jim ; -unknown-(HOME), ph: (03) 5555 6473(WORK); MALE; birthDate: Dec 25, 1974; active

assessor: Generated Summary: 23; Adam Careful

status: COMPLETED

date: Dec 6, 2014 10:33:00 PM

description: This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident

problem: MVA

Investigations

IdExtensionModifierExtensionCodeItem
Initial Examination (Details )deep laceration of the scalp (left temporo-occipital)

summary: provisional diagnoses of laceration of head and traumatic brain injury (TBI)

Findings

IdExtensionModifierExtensionItemCause
850.0 (Details : {ICD-9 code '850.0' = '850.0)

plan: hospital standard closed head injury management protocol

 

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.