2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

4.7.7 Resource ClinicalAssessment - Examples

Example Index:

Example of clinicalassessmentXMLJSON

4.7.7.1 General

XML

Example of clinicalassessment (id = "example")

Raw XML

<ClinicalAssessment xmlns="http://hl7.org/fhir">
  <id value="example"/>
  <patient>
    <reference value="Patient/example"/>
  </patient>  
  <assessor>
    <reference value="Practitioner/example"/>
  </assessor>
  <date value="2014-12-06T22:33:00+11:00"/>
  <description value="This 26 yo male patient is brought into ER by ambulance after being involved in a motor
   vehicle accident"/>
  <problem>
    <display value="MVA"/> <!--   todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event)
       -->
  </problem>
  <investigations>
    <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>
  </investigations>
  <summary value="provisional diagnoses of laceration of head and traumatic brain injury (TBI)"/>
  <diagnosis>
    <item>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-9"/>
        <code value="850.0"/>
      </coding>
    </item>
  </diagnosis>
  <plan>
    <!--   in real life, this would be a reference   -->
    <display value="hospital standard closed head injury management protocol "/>
  </plan>
</ClinicalAssessment>

JSON

Example of clinicalassessment

Raw JSON (Canonical)

{
  "resourceType": "ClinicalAssessment",
  "id": "example",
  "patient": {
    "reference": "Patient/example"
  },
  "assessor": {
    "reference": "Practitioner/example"
  },
  "date": "2014-12-06T22:33:00+11:00",
  "description": "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident",
  "problem": [
    {
      "display": "MVA"
    }
  ],
  "investigations": [
    {
      "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)",
  "diagnosis": [
    {
      "item": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/icd-9",
            "code": "850.0"
          }
        ]
      }
    }
  ],
  "plan": {
    "display": "hospital standard closed head injury management protocol "
  }
}

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.