Release 4B Ballot #1

This page is part of the FHIR Specification (v4.1.0: Release 4B 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 Group

Maturity Level: N/A

Standards Status: Informative

Compartments: Encounter, Patient, Practitioner

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

Generated Narrative

identifier: id: 12345

status: completed

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

subject: Generated Summary: Medical record number: 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); , Phone: (03) 5555 6473, Phone: (03) 3410 5613, Phone: (03) 5555 8834; gender: male; birthDate: 1974-12-25;

encounter: Generated Summary: status: in-progress; inpatient encounter

effective: 6 Dec. 2014, 8:00:00 pm --> 6 Dec. 2014, 10:33:00 pm

date: 6 Dec. 2014, 10:33:00 pm

assessor: Generated Summary: id: 23; active; Adam Careful

problem: MVA

Investigations

-

Code

Item

*

Initial Examination

deep laceration of the scalp (left temporo-occipital), decreased level of consciousness, disoriented to time and place, restless

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

Findings

-

ItemCodeableConcept

*

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.