This page is part of the FHIR Specification (v4.3.0: R4B - STU). 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
Patient Care Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Encounter, Patient, Practitioner |
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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 ------------------------------------------------------------------- <http://hl7.org/fhir/ClinicalImpression/example> 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</b></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 "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>assessor</b>: <a href=\"practitioner-example.html\">Practitioner/example</a> "Adam CAREFUL"</p><p><b>problem</b>: <span>: MVA</span></p><h3>Investigations</h3><table class=\"grid\"><tr><td>-</td><td><b>Code</b></td><td><b>Item</b></td></tr><tr><td>*</td><td>Initial Examination <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></td><td><span>: deep laceration of the scalp (left temporo-occipital)</span>, <span>: decreased level of consciousness</span>, <span>: disoriented to time and place</span>, <span>: restless</span></td></tr></table><p><b>summary</b>: provisional diagnoses of laceration of head and traumatic brain injury (TBI)</p><h3>Findings</h3><table class=\"grid\"><tr><td>-</td><td><b>ItemCodeableConcept</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></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:link <http://hl7.org/fhir/Patient/example>; fhir:Reference.reference [ fhir:value "Patient/example" ] ]; fhir:ClinicalImpression.encounter [ fhir:link <http://hl7.org/fhir/Encounter/example>; 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.assessor [ fhir:link <http://hl7.org/fhir/Practitioner/example>; fhir:Reference.reference [ fhir:value "Practitioner/example" ] ]; fhir:ClinicalImpression.problem [ fhir:index 0; fhir:Reference.display [ fhir:value "MVA" ] ]; fhir:ClinicalImpression.investigation [ fhir:index 0; fhir:ClinicalImpression.investigation.code [ fhir:CodeableConcept.text [ fhir:value "Initial Examination" ] ]; fhir:ClinicalImpression.investigation.item [ fhir:index 0; fhir:Reference.display [ fhir:value "deep laceration of the scalp (left temporo-occipital)" ] ], [ fhir:index 1; fhir:Reference.display [ fhir:value "decreased level of consciousness" ] ], [ fhir:index 2; fhir:Reference.display [ fhir:value "disoriented to time and place" ] ], [ fhir:index 3; fhir:Reference.display [ fhir:value "restless" ] ] ]; fhir:ClinicalImpression.summary [ fhir:value "provisional diagnoses of laceration of head and traumatic brain injury (TBI)"]; fhir:ClinicalImpression.finding [ fhir:index 0; fhir:ClinicalImpression.finding.itemCodeableConcept [ 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" ] ] ] ] . <http://hl7.org/fhir/Patient/example> a fhir:Patient . <http://hl7.org/fhir/Encounter/example> a fhir:Encounter . <http://hl7.org/fhir/Practitioner/example> a fhir:Practitioner . # - ontology header ------------------------------------------------------------ <http://hl7.org/fhir/ClinicalImpression/example.ttl> a owl:Ontology; owl:imports fhir:fhir.ttl; owl:versionIRI <http://build.fhir.org/ClinicalImpression/example.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.