Clinical
Summary
This
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Specification
(v4.0.1:
R4
(v5.0.0:
R5
-
Mixed
Normative
and
STU
)
).
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The
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| Patient Care Work Group | Maturity Level : N/A | Standards Status : Informative | Compartments : Encounter , Patient , Practitioner |
Raw JSON ( canonical form + also see JSON Format Specification )
Example of clinicalimpression
{
"resourceType": "ClinicalImpression",
"id": "example",
"text": {
"status": "generated",
"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 --> 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>"
"resourceType" : "ClinicalImpression",
"id" : "example",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ClinicalImpression</b><a name=\"example\"> </a></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 ClinicalImpression "example" </p></div><p><b>identifier</b>: id:\u00a012345</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>performer</b>: <a href=\"practitioner-example.html\">Practitioner/example</a> "Adam CAREFUL"</p><p><b>problem</b>: <span>: MVA</span></p><p><b>summary</b>: <span title=\" \n <investigation>\n <code>\n <text value="Initial Examination"/>\n </code>\n <item>\n <display value="deep laceration of the scalp (left temporo-occipital)"/>\n </item>\n <item>\n <display value="decreased level of consciousness"/>\n </item>\n <item>\n <display value="disoriented to time and place"/>\n </item>\n <item>\n <display value="restless"/>\n </item>\n </investigation>\n \">provisional diagnoses of laceration of head and traumatic brain injury (TBI)</span></p><blockquote><p><b>finding</b></p><h3>Items</h3><table class=\"grid\"><tr><td>-</td><td><b>Concept</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></blockquote></div>"
},
"identifier": [
{
"value": "12345"
}
],
"status": "completed",
"description": "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident",
"subject": {
"reference": "Patient/example"
"identifier" : [{
"value" : "12345"
}],
"status" : "completed",
"description" : "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident",
"subject" : {
"reference" : "Patient/example"
},
"encounter": {
"reference": "Encounter/example"
"encounter" : {
"reference" : "Encounter/example"
},
"effectivePeriod": {
"start": "2014-12-06T20:00:00+11:00",
"end": "2014-12-06T22:33:00+11:00"
"effectivePeriod" : {
"start" : "2014-12-06T20:00:00+11:00",
"end" : "2014-12-06T22:33:00+11:00"
},
"date": "2014-12-06T22:33:00+11:00",
"assessor": {
"reference": "Practitioner/example"
"date" : "2014-12-06T22:33:00+11:00",
"performer" : {
"reference" : "Practitioner/example"
},
"problem": [
{
"display": "MVA"
}
],
"investigation": [
{
"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)",
"finding": [
{
"itemCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/sid/icd-9",
"code": "850.0"
}
]
"problem" : [{
"display" : "MVA"
}],
"summary" : "provisional diagnoses of laceration of head and traumatic brain injury (TBI)",
"finding" : [{
"item" : {
"concept" : {
"coding" : [{
"system" : "http://hl7.org/fhir/sid/icd-9",
"code" : "850.0"
}]
}
}
]
}]
}
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.
FHIR
®©
HL7.org
2011+.
FHIR
Release
4
(Technical
Correction
#1)
(v4.0.1)
R5
hl7.fhir.core#5.0.0
generated
on
Fri,
Nov
1,
2019
09:34+1100.
QA
Page
Sun,
Mar
26,
2023
15:24+1100.
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