R4 Draft for Comment

This page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). 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

Patient Care Work GroupMaturity Level: N/ABallot Status: InformativeCompartments: Encounter, Patient, Practitioner

This is the narrative for the resource. See also the XML or JSON format. This example conforms to the profile ClinicalImpression.


Generated Narrative with Details

id: example

identifier: 12345

status: completed

description: This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident

subject: Patient/example

context: Encounter/example

effective: 06/12/2014 8:00:00 PM --> 06/12/2014 10:33:00 PM

date: 06/12/2014 10:33:00 PM

assessor: Practitioner/example

problem: MVA

Investigations

-CodeItem
*Initial Examination (Details )deep laceration of the scalp (left temporo-occipital)

summary: provisional diagnoses of laceration of head and traumatic brain injury (TBI)

Findings

-Item[x]
*850.0 (Details : {ICD-9 code '850.0' = '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.