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Clinicalimpression-example.xml

Patient Care Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Encounter, Patient, Practitioner

Raw XML (canonical form + also see XML Format Specification)

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Example of clinicalimpression (id = "example")

<?xml version="1.0" encoding="UTF-8"?>

<ClinicalImpression xmlns="http://hl7.org/fhir">
  <id value="example"/> 
  <text> <status value="generated"/> <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> </text> <identifier> 
       <value value="12345"/> 
  </identifier> 
  <status value="completed"/> 
  <description value="This 26 yo male patient is brought into ER by ambulance after being involved in a motor
   vehicle accident"/> 
  <subject> 
    <reference value="Patient/example"/> 
  </subject>   
  <encounter> 
    <reference value="Encounter/example"/> 
  </encounter> 
  <effectivePeriod> 
      <start value="2014-12-06T20:00:00+11:00"/> 
      <end value="2014-12-06T22:33:00+11:00"/> 
  </effectivePeriod> 
  <date value="2014-12-06T22:33:00+11:00"/> 
  <performer> 
    <reference value="Practitioner/example"/> 
  </performer> 
  <problem> 
    <display value="MVA"/>  <!--    todo: reference to condition with snomed code 418399005 : Motor vehicle accident (event)
        -->
  </problem> 
 <!--   
   <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>
     -->
  <summary value="provisional diagnoses of laceration of head and traumatic brain injury (TBI)"/> 
  <finding> 
    <item> 
      <concept> 
        <coding> 
          <system value="http://hl7.org/fhir/sid/icd-9"/> 
          <code value="850.0"/> 
        </coding> 
      </concept> 
    </item> 
  </finding> 
</ClinicalImpression> 

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.