DSTU2 Ballot Source

This page is part of the FHIR Specification (v0.5.0: DSTU 2 Ballot 2). 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 R2

Clinicalimpression-example.xml

Raw XML (canonical form)

Example of clinicalimpression (id = "example")

Raw XML

<ClinicalImpression xmlns="http://hl7.org/fhir">
  <id value="example"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <patient>
    <reference value="Patient/example"/>
  </patient>
  <assessor>
    <reference value="Practitioner/example"/>
  </assessor>
  <status value="completed"/>
  <date value="2014-12-06T22:33:00+11:00"/>
  <description value="This 26 yo male patient is brought into ER by ambulance after being involved in a motor
   vehicle accident"/>
  <problem>
    <display value="MVA"/>
  </problem><!--    todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event)
      -->
  <investigations>
    <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>
  </investigations>
  <summary value="provisional diagnoses of laceration of head and traumatic brain injury (TBI)"/>
  <finding>
    <item>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-9"/>
        <code value="850.0"/>
      </coding>
    </item>
  </finding>
  <plan><!--    in real life, this would be a reference    -->
    <display value="hospital standard closed head injury management protocol "/>
  </plan>
</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.