Clinical SummaryThis is Snapshot #3 for FHIR R5, released to support Connectathon 32. For a full list of available versions, see the Directory of published versions.
| Patient Care Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: 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 "example" </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> "Peter CHALMERS"</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 --> 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> "Adam CAREFUL"</p><p><b>problem</b>: <span>: MVA</span></p><p><b>summary</b>: <span title=\" \n <investigation>\n <code>\n <text value="Initial Examination"/>\n </code>\n <item>\n <display value="deep laceration of the scalp (left temporo-occipital)"/>\n </item>\n <item>\n <display value="decreased level of consciousness"/>\n </item>\n <item>\n <display value="disoriented to time and place"/>\n </item>\n <item>\n <display value="restless"/>\n </item>\n </investigation>\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.
FHIR ®© HL7.org 2011+. FHIR R5 Ballot hl7.fhir.core#5.0.0-snapshot3 generated on Wed, Dec 14, 2022 07:16+1100.
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