Clinicalimpression-example.xml

Example of clinicalimpression (id = "example")

<?xml version="1.0" encoding="UTF-8"?>

<ClinicalImpression xmlns="http://hl7.org/fhir">
  <id value="example"/> 
  <text> <status value="generated"/> <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> </text> <identifier> 
       <value value="12345"/> 
  </identifier> 
  <status value="completed"/> 
  <description value="This 26 yo male patient is brought into ER by ambulance after being involved in a motor
   vehicle accident"/> 
  <subject> 
    <reference value="Patient/example"/> 
  </subject>   
  <encounter> 
    <reference value="Encounter/example"/> 
  </encounter> 
  <effectivePeriod> 
      <start value="2014-12-06T20:00:00+11:00"/> 
      <end value="2014-12-06T22:33:00+11:00"/> 
  </effectivePeriod> 
  <date value="2014-12-06T22:33:00+11:00"/> 
  <assessor> 
    <reference value="Practitioner/example"/> 
  </assessor> 
  <problem> 
    <display value="MVA"/>  <!--    todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event)
        -->
  </problem> 
  <investigation> 
    <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> 
  </investigation> 
  <summary value="provisional diagnoses of laceration of head and traumatic brain injury (TBI)"/> 
  <finding> 
    <itemCodeableConcept> 
      <coding> 
        <system value="http://hl7.org/fhir/sid/icd-9"/> 
        <code value="850.0"/> 
      </coding> 
    </itemCodeableConcept> 
  </finding> 
</ClinicalImpression>