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.json

Raw JSON (canonical form)

Example of clinicalimpression

{
  "resourceType": "ClinicalImpression",
  "id": "example",
  "text": {
    "status": "generated",
    "div": "<div>!-- Snipped for Brevity --></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": [
    {
      "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)",
  "finding": [
    {
      "item": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/icd-9",
            "code": "850.0"
          }
        ]
      }
    }
  ],
  "plan": [
    {
      "display": "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.