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
Example of clinicalimpression
@prefix fhir: <http://hl7.org/fhir/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- <http://hl7.org/fhir/ClinicalImpression/example> a fhir:ClinicalImpression; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "example"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.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>" ]; fhir:ClinicalImpression.status [ fhir:value "completed"]; fhir:ClinicalImpression.description [ fhir:value "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident"]; fhir:ClinicalImpression.subject [ fhir:link <http://hl7.org/fhir/Patient/example>; fhir:Reference.reference [ fhir:value "Patient/example" ] ]; fhir:ClinicalImpression.assessor [ fhir:link <http://hl7.org/fhir/Practitioner/example>; fhir:Reference.reference [ fhir:value "Practitioner/example" ] ]; fhir:ClinicalImpression.date [ fhir:value "2014-12-06T22:33:00+11:00"^^xsd:dateTime]; fhir:ClinicalImpression.problem [ fhir:index 0; fhir:Reference.display [ fhir:value "MVA" ] ]; fhir:ClinicalImpression.investigations [ fhir:index 0; fhir:ClinicalImpression.investigations.code [ fhir:CodeableConcept.text [ fhir:value "Initial Examination" ] ]; fhir:ClinicalImpression.investigations.item [ fhir:index 0; fhir:Reference.display [ fhir:value "deep laceration of the scalp (left temporo-occipital)" ] ], [ fhir:index 1; fhir:Reference.display [ fhir:value "decreased level of consciousness" ] ], [ fhir:index 2; fhir:Reference.display [ fhir:value "disoriented to time and place" ] ], [ fhir:index 3; fhir:Reference.display [ fhir:value "restless" ] ] ]; fhir:ClinicalImpression.summary [ fhir:value "provisional diagnoses of laceration of head and traumatic brain injury (TBI)"]; fhir:ClinicalImpression.finding [ fhir:index 0; fhir:ClinicalImpression.finding.itemCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-9" ]; fhir:Coding.code [ fhir:value "850.0" ] ] ] ]; fhir:ClinicalImpression.plan [ fhir:index 0; fhir:Reference.display [ fhir:value "hospital standard closed head injury management protocol " ] ] . <http://hl7.org/fhir/Patient/example> a fhir:Patient . <http://hl7.org/fhir/Practitioner/example> a fhir:Practitioner . # -------------------------------------------------------------------------------------
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.