Clinicalimpression-example.xml

Example of clinicalimpression (id = "example")

<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 with Details</b> </p> <p> <b> id</b> : example</p> <p> <b> identifier</b> : 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> Patient/example</a> </p> <p> <b> context</b> : <a> Encounter/example</a> </p> <p> <b> effective</b> : 06/12/2014 8:00:00 PM --&gt; 06/12/2014 10:33:00 PM</p> <p> <b> date</b> : 06/12/2014 10:33:00 PM</p> <p> <b> assessor</b> : <a> Practitioner/example</a> </p> <p> <b> problem</b> : MVA</p> <h3> Investigations</h3> <table> <tr> <td> -</td> <td> <b> Code</b> </td> <td> <b> Item</b> </td> </tr> <tr> <td> *</td> <td> Initial Examination <span> (Details )</span> </td> <td> deep laceration of the scalp (left temporo-occipital)</td> </tr> </table> <p> <b> summary</b> : provisional diagnoses of laceration of head and traumatic brain injury (TBI)</p> <h3> Findings</h3> <table> <tr> <td> -</td> <td> <b> Item[x]</b> </td> </tr> <tr> <td> *</td> <td> 850.0 <span> (Details : {ICD-9 code '850.0' = '850.0)</span> </td> </tr> </table> </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>   
  <context> 
    <reference value="Encounter/example"/> 
  </context> 
  <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"/> 
  <assessor> 
    <reference value="Practitioner/example"/> 
  </assessor> 
  <problem> 
    <display value="MVA"/>  <!--    todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event)
        -->
  </problem> 
  <investigation> 
    <code> 
      <text value="Initial Examination"/> 
    </code> 
    <!--    todo: turn all of these into observations    -->
    <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> 
    <itemCodeableConcept> 
      <coding> 
        <system value="http://hl7.org/fhir/sid/icd-9"/> 
        <code value="850.0"/> 
      </coding> 
    </itemCodeableConcept> 
  </finding> 
</ClinicalImpression>