STU3 Candidate

This page is part of the FHIR Specification (v1.8.0: STU 3 Draft). 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.xml

Raw XML (canonical form)

Example of clinicalimpression (id = "example")

<ClinicalImpression xmlns="http://hl7.org/fhir">
  <id value="example"/>
  <text><status value="generated"/><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>850.0 <span>(Details : {ICD-9 code '850.0' = '850.0)</span></td></tr></table></div></text><status value="completed"/>
  <description value="This 26 yo male patient is brought into ER by ambulance after being involved in a motor
   vehicle accident"/>
  <subject>
    <reference value="Patient/example"/>
  </subject>  
  <assessor>
    <reference value="Practitioner/example"/>
  </assessor>
  <date value="2014-12-06T22:33:00+11:00"/>
  <problem>
    <display value="MVA"/> <!--    todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event)
        -->
  </problem>
  <investigation>
    <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>
  </investigation>
  <summary value="provisional diagnoses of laceration of head and traumatic brain injury (TBI)"/>
  <finding>
    <itemCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-9"/>
        <code value="850.0"/>
      </coding>
    </itemCodeableConcept>
  </finding>
</ClinicalImpression>

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.