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ClinicalImpression "example" Version "1"

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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

encounter: Encounter/example

effective: Dec 6, 2014 8:00:00 PM --> Dec 6, 2014 10:33:00 PM

date: Dec 6, 2014 10:33:00 PM

assessor: Practitioner/example

problem: MVA

Investigations

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

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

Findings

-ItemCodeableConcept
*850.0 (Details : {ICD-9 code '850.0' = '850.0)

{
  "resourceType" : "ClinicalImpression",
  "id" : "example",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:01:34.317Z"
  },
  "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>: 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>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>"
  },
  "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",
  "assessor" : {
    "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"
          }
        ]
      }
    }
  ]
}