Release 5 Preview #2

Clinicalimpression-example.json

Patient Care Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: 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</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>Generated Summary: id: example; Medical record number = 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); -unknown-(HOME), ph: (03) 5555 6473(WORK), ph: (03) 3410 5613(MOBILE), ph: (03) 5555 8834(OLD); gender: male; birthDate: 1974-12-25; </a></p><p><b>encounter</b>: <a>Generated Summary: id: example; status: in-progress; <span>inpatient encounter</span></a></p><p><b>effective</b>: Dec 6, 2014 8:00:00 PM --&gt; Dec 6, 2014 10:33:00 PM</p><p><b>date</b>: Dec 6, 2014 10:33:00 PM</p><p><b>performer</b>: <a>Generated Summary: id: example; 23; active; Adam Careful </a></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><h3>Findings</h3><table><tr><td>-</td><td><b>Item</b></td></tr><tr><td>*</td><td/></tr></table></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"
  },
  "encounter": {
    "reference": "Encounter/example"
  },
  "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",
  "performer": {
    "reference": "Practitioner/example"
  },
  "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.