This page is part of the FHIR Specification (v4.3.0: R4B - STU). 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> <div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource "example" </p> </div> <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 href="patient-example.html">Patient/example</a> "Peter CHALMERS"</p> <p> <b> encounter</b> : <a href="encounter-example.html">Encounter/example</a> </p> <p> <b> effective</b> : 2014-12-06T20:00:00+11:00 --> 2014-12-06T22:33:00+11:00</p> <p> <b> date</b> : 2014-12-06T22:33:00+11:00</p> <p> <b> assessor</b> : <a href="practitioner-example.html">Practitioner/example</a> "Adam CAREFUL"</p> <p> <b> problem</b> : <span> : MVA</span> </p> <h3> Investigations</h3> <table class="grid"><tr> <td> -</td> <td> <b> Code</b> </td> <td> <b> Item</b> </td> </tr> <tr> <td> *</td> <td> Initial Examination <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> ()</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 class="grid"><tr> <td> -</td> <td> <b> ItemCodeableConcept</b> </td> </tr> <tr> <td> *</td> <td> 850.0 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (ICD-9#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>
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.