Clinicalimpression-example.json

Example of clinicalimpression

{
  "resourceType": "ClinicalImpression",
  "id": "example",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: 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>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; </a></p><p><b>encounter</b>: <a>Generated Summary: status: in-progress; <span>inpatient encounter</span></a></p><p><b>effective</b>: 6 Dec. 2014, 8:00:00 pm --&gt; 6 Dec. 2014, 10:33:00 pm</p><p><b>date</b>: 6 Dec. 2014, 10:33:00 pm</p><p><b>assessor</b>: <a>Generated Summary: id: 23; active; Adam Careful </a></p><p><b>problem</b>: <span>MVA</span></p><h3>Investigations</h3><table><tr><td>-</td><td><b>Code</b></td><td><b>Item</b></td></tr><tr><td>*</td><td><span>Initial Examination</span></td><td><span>deep laceration of the scalp (left temporo-occipital)</span>, <span>decreased level of consciousness</span>, <span>disoriented to time and place</span>, <span>restless</span></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><span>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"
  },
  "encounter": {
    "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"
          }
        ]
      }
    }
  ]
}