This page is part of the FHIR Specification (v3.5a.0: R4 Ballot 4). 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
| Patient Care Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Encounter, Patient, Practitioner |
Raw JSON (canonical form + also see JSON Format Specification)
Example of clinicalimpression
{
"resourceType": "ClinicalImpression",
"id": "example",
"text": {
"status": "generated",
"div": "<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 --> 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>ItemCodeableConcept</b></td></tr><tr><td>*</td><td>850.0 <span>(Details : {ICD-9 code '850.0' = '850.0)</span></td></tr></table></div>"
},
"identifier": [
{
"value": "12345"
}
],
"status": "completed",
"description": "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident",
"subject": {
"reference": "Patient/example"
},
"context": {
"reference": "Encounter/example"
},
"effectivePeriod": {
"start": "2014-12-06T20:00:00+11:00",
"end": "2014-12-06T22:33:00+11:00"
},
"date": "2014-12-06T22:33:00+11:00",
"assessor": {
"reference": "Practitioner/example"
},
"problem": [
{
"display": "MVA"
}
],
"investigation": [
{
"code": {
"text": "Initial Examination"
},
"item": [
{
"display": "deep laceration of the scalp (left temporo-occipital)"
},
{
"display": "decreased level of consciousness"
},
{
"display": "disoriented to time and place"
},
{
"display": "restless"
}
]
}
],
"summary": "provisional diagnoses of laceration of head and traumatic brain injury (TBI)",
"finding": [
{
"itemCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-9",
"code": "850.0"
}
]
}
}
]
}
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.