DSTU2 FHIR Release 3 (STU)

This page is part of the FHIR Specification (v1.0.2: DSTU (v3.0.2: STU 2). 3). 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 R3 R2

Clinicalimpression-example

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

This is the narrative for the resource. See also the XML or JSON format. This example conforms to the profile ClinicalImpression .

Generated Narrative with Details

id : example

identifier : 12345

status : completed

description : This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident

subject : Patient/example

assessor context : Practitioner/example Encounter/example

status effective : completed 06/12/2014 8:00:00 PM --> 06/12/2014 10:33:00 PM

date : 06/12/2014 10:33:00 PM

description assessor : This 26 yo male patient is brought into ER by ambulance after being involved in a motor vehicle accident Practitioner/example

problem : MVA

Investigations

- Code Item
* Initial Examination (Details ) deep laceration of the scalp (left temporo-occipital)

summary : provisional diagnoses of laceration of head and traumatic brain injury (TBI)

Findings

- Item Item[x]
* ?? 850.0 (Details : {ICD-9 code '850.0' = '??) '850.0)
plan : 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.