Snapshot 3: Connectathon 32 Base

This is Snapshot #3 for FHIR R5, released to support Connectathon 32. For a full list of available versions, see the Directory of published versions.

Example ClinicalImpression/example (Turtle)

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

Raw Turtle (+ also see Turtle/RDF Format Specification)

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 -------------------------------------------------------------------

[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: 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=\" \n   &lt;investigation&gt;\n    &lt;code&gt;\n      &lt;text value=&quot;Initial Examination&quot;/&gt;\n    &lt;/code&gt;\n    &lt;item&gt;\n      &lt;display value=&quot;deep laceration of the scalp (left temporo-occipital)&quot;/&gt;\n    &lt;/item&gt;\n    &lt;item&gt;\n      &lt;display value=&quot;decreased level of consciousness&quot;/&gt;\n    &lt;/item&gt;\n    &lt;item&gt;\n      &lt;display value=&quot;disoriented to time and place&quot;/&gt;\n    &lt;/item&gt;\n    &lt;item&gt;\n      &lt;display value=&quot;restless&quot;/&gt;\n    &lt;/item&gt;\n  &lt;/investigation&gt;\n   \">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>"
  ]; # 
  fhir:ClinicalImpression.identifier [
     fhir:index 0;
     fhir:Identifier.value [ fhir:value "12345" ]
  ]; # 
  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:Reference.reference [ fhir:value "Patient/example" ]
  ]; # 
  fhir:ClinicalImpression.encounter [
     fhir:Reference.reference [ fhir:value "Encounter/example" ]
  ]; # 
  fhir:ClinicalImpression.effectivePeriod [
     fhir:Period.start [ fhir:value "2014-12-06T20:00:00+11:00"^^xsd:dateTime ];
     fhir:Period.end [ fhir:value "2014-12-06T22:33:00+11:00"^^xsd:dateTime ]
  ]; # 
  fhir:ClinicalImpression.date [ fhir:value "2014-12-06T22:33:00+11:00"^^xsd:dateTime]; # 
  fhir:ClinicalImpression.performer [
     fhir:Reference.reference [ fhir:value "Practitioner/example" ]
  ]; # 
  fhir:ClinicalImpression.problem [
     fhir:index 0;
     fhir:Reference.display [ fhir:value "MVA" ]
  ]; #    todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event)   
  fhir:ClinicalImpression.summary [ fhir:value "provisional diagnoses of laceration of head and traumatic brain injury (TBI)"]; #   
   <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>
    
  fhir:ClinicalImpression.finding [
     fhir:index 0;
     fhir:ClinicalImpression.finding.item [
       fhir:CodeableReference.concept [
         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" ]
         ]
       ]
     ]
  ]] . # 

# - ontology header ------------------------------------------------------------

[a owl:Ontology;
  owl:imports fhir:fhir.ttl] .

# -------------------------------------------------------------------------------------


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.