Release 5 Ballot

This page is part of the FHIR Specification (v5.0.0-ballot: R5 Ballot - see ballot notes). 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 ClinicalImpression/example (XML)

Patient Care Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Encounter, Patient, Practitioner

Raw XML (canonical form + also see XML Format Specification)

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Example of clinicalimpression (id = "example")

<?xml version="1.0" encoding="UTF-8"?>

<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: ClinicalImpression</b> <a name="example"> </a> </p> <div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border:
       1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource ClinicalImpression &quot;example&quot; </p> </div> <p> <b> identifier</b> : id: 12345</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 href="patient-example.html">Patient/example</a>  &quot;Peter CHALMERS&quot;</p> <p> <b> encounter</b> : <a href="encounter-example.html">Encounter/example</a> </p> <p> <b> effective</b> : 2014-12-06T20:00:00+11:00 --&gt; 2014-12-06T22:33:00+11:00</p> <p> <b> date</b> : 2014-12-06T22:33:00+11:00</p> <p> <b> performer</b> : <a href="practitioner-example.html">Practitioner/example</a>  &quot;Adam CAREFUL&quot;</p> <p> <b> problem</b> : <span> : MVA</span> </p> <p> <b> summary</b> : <span title=" 
   &lt;investigation&gt;
    &lt;code&gt;
      &lt;text value=&quot;Initial Examination&quot;/&gt;
    &lt;/code&gt;
    &lt;item&gt;
      &lt;display value=&quot;deep laceration of the scalp (left temporo-occipital)&quot;/&gt
        ;
    &lt;/item&gt;
    &lt;item&gt;
      &lt;display value=&quot;decreased level of consciousness&quot;/&gt;
    &lt;/item&gt;
    &lt;item&gt;
      &lt;display value=&quot;disoriented to time and place&quot;/&gt;
    &lt;/item&gt;
    &lt;item&gt;
      &lt;display value=&quot;restless&quot;/&gt;
    &lt;/item&gt;
  &lt;/investigation&gt;
   ">provisional diagnoses of laceration of head and traumatic brain injury (TBI)</span> </p> <blockquote> <p> <b> finding</b> </p> <h3> Items</h3> <table class="grid"><tr> <td> -</td> <td> <b> Concept</b> </td> </tr> <tr> <td> *</td> <td> 850.0 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (ICD-9#850.0)</span> </td> </tr> </table> </blockquote> </div> </text> <identifier> 
       <value value="12345"/> 
  </identifier> 
  <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>   
  <encounter> 
    <reference value="Encounter/example"/> 
  </encounter> 
  <effectivePeriod> 
      <start value="2014-12-06T20:00:00+11:00"/> 
      <end value="2014-12-06T22:33:00+11:00"/> 
  </effectivePeriod> 
  <date value="2014-12-06T22:33:00+11:00"/> 
  <performer> 
    <reference value="Practitioner/example"/> 
  </performer> 
  <problem> 
    <display value="MVA"/>  <!--    todo: reference to condition with snomed code 418399005 : Motor vehicle accident
     (event)    -->
  </problem> 
 <!--   
   <investigation>
    <code>
      <text value="Initial Examination"/>
    </code>
    <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> 
    <item> 
      <concept> 
        <coding> 
          <system value="http://hl7.org/fhir/sid/icd-9"/> 
          <code value="850.0"/> 
        </coding> 
      </concept> 
    </item> 
  </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.