Release 4 5 Snapshot #1

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Clinicalimpression-example.ttl

Patient Care Work Group Maturity Level : N/A Standards Status : Informative Compartments : Encounter , Patient , Practitioner

Raw Turtle (+ also see Turtle/RDF Format Specification )

Example of clinicalimpression

@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

<http://hl7.org/fhir/ClinicalImpression/example> a fhir:ClinicalImpression;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "example"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: example</p><p><b>identifier</b>: 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>Patient/example</a></p><p><b>encounter</b>: <a>Encounter/example</a></p><p><b>effective</b>: 06/12/2014 8:00:00 PM --&gt; 06/12/2014 10:33:00 PM</p><p><b>date</b>: 06/12/2014 10:33:00 PM</p><p><b>assessor</b>: <a>Practitioner/example</a></p><p><b>problem</b>: MVA</p><h3>Investigations</h3><table><tr><td>-</td><td><b>Code</b></td><td><b>Item</b></td></tr><tr><td>*</td><td>Initial Examination <span>(Details )</span></td><td>deep laceration of the scalp (left temporo-occipital)</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>850.0 <span>(Details : {ICD-9 code '850.0' = '850.0)</span></td></tr></table></div>"

     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><div><p>Resource &quot;example&quot; </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>Patient/example</a> &quot;Peter CHALMERS&quot;</p><p><b>encounter</b>: <a>Encounter/example</a></p><p><b>effective</b>: 2014-12-06T20:00:00+11:00 --&gt; 2014-12-06T22:33:00+11:00</p><p><b>date</b>: 2014-12-06T22:33:00+11:00</p><p><b>performer</b>: <a>Practitioner/example</a> &quot;Adam CAREFUL&quot;</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></blockquote></div>"

  ];
  fhir:ClinicalImpression.identifier [
     fhir:index 0;
     fhir:Identifier.value [ fhir:value "12345" ]
  ];
  fhir:ClinicalImpression.status [ fhir:value "completed"];
  fhir:ClinicalImpression.description [ fhir:value "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident"];
  fhir:ClinicalImpression.subject [
     fhir:link <http://hl7.org/fhir/Patient/example>;
     fhir:Reference.reference [ fhir:value "Patient/example" ]
  ];
  fhir:ClinicalImpression.encounter [
     fhir:link <http://hl7.org/fhir/Encounter/example>;
     fhir:Reference.reference [ fhir:value "Encounter/example" ]
  ];
  fhir:ClinicalImpression.effectivePeriod [
     fhir:Period.start [ fhir:value "2014-12-06T20:00:00+11:00"^^xsd:dateTime ];
     fhir:Period.end [ fhir:value "2014-12-06T22:33:00+11:00"^^xsd:dateTime ]
  ];
  fhir:ClinicalImpression.date [ fhir:value "2014-12-06T22:33:00+11:00"^^xsd:dateTime];
  fhir:ClinicalImpression.assessor [

  fhir:ClinicalImpression.performer [

     fhir:link <http://hl7.org/fhir/Practitioner/example>;
     fhir:Reference.reference [ fhir:value "Practitioner/example" ]
  ];
  fhir:ClinicalImpression.problem [
     fhir:index 0;
     fhir:Reference.display [ fhir:value "MVA" ]
  ];
  fhir:ClinicalImpression.investigation [
     fhir:index 0;
     fhir:ClinicalImpression.investigation.code [
       fhir:CodeableConcept.text [ fhir:value "Initial Examination" ]
     ];
     fhir:ClinicalImpression.investigation.item [
       fhir:index 0;
       fhir:Reference.display [ fhir:value "deep laceration of the scalp (left temporo-occipital)" ]
     ], [
       fhir:index 1;
       fhir:Reference.display [ fhir:value "decreased level of consciousness" ]
     ], [
       fhir:index 2;
       fhir:Reference.display [ fhir:value "disoriented to time and place" ]
     ], [
       fhir:index 3;
       fhir:Reference.display [ fhir:value "restless" ]
     ]
  ];

  fhir:ClinicalImpression.summary [ fhir:value "provisional diagnoses of laceration of head and traumatic brain injury (TBI)"];
  fhir:ClinicalImpression.finding [
     fhir:index 0;
     fhir:ClinicalImpression.finding.itemCodeableConcept [
       fhir:CodeableConcept.coding [
         fhir:index 0;
         fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-9" ];
         fhir:Coding.code [ fhir:value "850.0" ]

     fhir:ClinicalImpression.finding.item [
       fhir:CodeableReference.concept [
         fhir:CodeableConcept.coding [
           fhir:index 0;
           fhir:Coding.system [ fhir:value "http://hl7.org/fhir/sid/icd-9" ];
           fhir:Coding.code [ fhir:value "850.0" ]
         ]

       ]
     ]
  ] .

<http://hl7.org/fhir/Patient/example> a fhir:Patient .

<http://hl7.org/fhir/Encounter/example> a fhir:Encounter .

<http://hl7.org/fhir/Practitioner/example> a fhir:Practitioner .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/ClinicalImpression/example.ttl> a owl:Ontology;
  owl:imports fhir:fhir.ttl;
  owl:versionIRI <http://build.fhir.org/ClinicalImpression/example.ttl> .

# -------------------------------------------------------------------------------------


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.