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ClinicalImpression "example" Version "1"

Created by SYSTEM () at 11/28/2017 8:28:10 AM(UTC)

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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

context: Encounter/example

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

date: 06/12/2014 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

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

<?xml version="1.0" encoding="UTF-8"?>
<ClinicalImpression xmlns="http://hl7.org/fhir">
  <id value="example"/>
  <meta>
    <versionId value="1"/>
    <lastUpdated value="2017-11-28T08:28:10Z"/>
  </meta>
  <text>
    <status value="generated"/>
    <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>context</b>:
        <a>Encounter/example</a>
      </p>
      <p>
        <b>effective</b>: 06/12/2014 8:00:00 PM --&gt; 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>Item[x]</b>
          </td>
        </tr>
        <tr>
          <td>*</td>
          <td>850.0
            <span>(Details : {ICD-9 code '850.0' = '850.0)</span>
          </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>
  <context>
    <reference value="Encounter/example"/>
  </context>
  <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"/>
  <assessor>
    <reference value="Practitioner/example"/>
  </assessor>
  <problem>
    <display value="MVA"/>
  </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>
    <itemCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-9"/>
        <code value="850.0"/>
      </coding>
    </itemCodeableConcept>
  </finding>
</ClinicalImpression>