This page is part of the FHIR Specification (v4.6.0: R5 Draft Ballot). 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 | Standards Status: Informative | Compartments: Encounter, Patient, Practitioner |
Raw XML (canonical form + also see XML Format Specification)
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 --> 6 Dec. 2014, 10:33:00 pm</p> <p> <b> date</b> : 6 Dec. 2014, 10:33:00 pm</p> <p> <b> performer</b> : <a> Generated Summary: id: 23; active; Adam Careful </a> </p> <p> <b> problem</b> : <span> MVA</span> </p> <p> <b> summary</b> : provisional diagnoses of laceration of head and traumatic brain injury (TBI)</p> <blockquote> <p> <b> finding</b> </p> <h3> Items</h3> <table> <tr> <td> -</td> </tr> <tr> <td> *</td> </tr> </table> </blockquote> </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"/> <performer> <reference value="Practitioner/example"/> </performer> <problem> <display value="MVA"/> <!-- todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event) --> </problem> <!-- <investigation> <code> <text value="Initial Examination"/> </code> <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> <item> <concept> <coding> <system value="http://hl7.org/fhir/sid/icd-9"/> <code value="850.0"/> </coding> </concept> </item> </finding> </ClinicalImpression>
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.