R6 Ballot (2nd Draft)

Publish-box (todo)

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)

Example of clinicalimpression (id = "example")

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

<ClinicalImpression xmlns="http://hl7.org/fhir">
  <id value="example"/> 
  <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> 
  <!--   todo: reference to condition with snomed code 418399005 : Motor vehicle accident
   (event)   -->
  <problem> 
    <display value="MVA"/> 
  </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.