Clinical
Summary
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| 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 --> 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: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: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" ][a fhir:ClinicalImpression ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "example"] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir: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: 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>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>" ] ; # fhir:identifier ( [ fhir:value [ fhir:v "12345" ] ] ) ; # fhir:status [ fhir:v "completed"] ; # fhir:description [ fhir:v "This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident"] ; # fhir:subject [ fhir:reference [ fhir:v "Patient/example" ] ] ; # fhir:encounter [ fhir:reference [ fhir:v "Encounter/example" ] ] ; # fhir:effective [ a fhir:Period ; fhir:start [ fhir:v "2014-12-06T20:00:00+11:00"^^xsd:dateTime ] ; fhir:end [ fhir:v "2014-12-06T22:33:00+11:00"^^xsd:dateTime ] ] ; # fhir:date [ fhir:v "2014-12-06T22:33:00+11:00"^^xsd:dateTime] ; # fhir:performer [ fhir:reference [ fhir:v "Practitioner/example" ] ] ; # fhir:problem ( [ fhir:display [ fhir:v "MVA" ] ] ) ; # todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event) fhir:summary [ fhir:v "provisional diagnoses of laceration of head and traumatic brain injury (TBI)"] ; # # <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> # fhir:finding ( [ fhir:item [ fhir:concept [ fhir:coding ( [ fhir:system [ fhir:v "http://hl7.org/fhir/sid/icd-9"^^xsd:anyURI ] ; fhir:code [ fhir:v "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.
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