This page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). 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
Example of clinicalimpression
{ "resourceType": "ClinicalImpression", "id": "example", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: example</p><p><b>status</b>: completed</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>subject</b>: <a>Patient/example</a></p><p><b>assessor</b>: <a>Practitioner/example</a></p><p><b>date</b>: 06/12/2014 10:33:00 PM</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[x]</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>" }, "status": "completed", "description": "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident", "subject": { "reference": "Patient/example" }, "assessor": { "reference": "Practitioner/example" }, "date": "2014-12-06T22:33:00+11:00", "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": [ { "itemCodeableConcept": { "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.