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ClinicalImpression "example" Version "1"

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Generated Narrative

identifier: id: 12345

status: completed

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

subject: Generated Summary: Medical record number: 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); , Phone: (03) 5555 6473, Phone: (03) 3410 5613, Phone: (03) 5555 8834; gender: male; birthDate: 1974-12-25;

encounter: Generated Summary: status: in-progress; inpatient encounter

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

date: 6 Dec. 2014, 10:33:00 pm

performer: Generated Summary: id: 23; active; Adam Careful

problem: MVA

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

finding

Items

-
*

{
  "resourceType" : "ClinicalImpression",
  "id" : "example",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2021-05-24T10:49:07.243Z",
    "tag" : [
      {
        "system" : "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code" : "HTEST",
        "display" : "test health data"
      }
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: 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: Medical record number: 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); , Phone: (03) 5555 6473, Phone: (03) 3410 5613, Phone: (03) 5555 8834; gender: male; birthDate: 1974-12-25; </a></p><p><b>encounter</b>: <a>Generated Summary: status: in-progress; <span>inpatient encounter</span></a></p><p><b>effective</b>: 6 Dec. 2014, 8:00:00 pm --&gt; 6 Dec. 2014, 10:33:00 pm</p><p><b>date</b>: 6 Dec. 2014, 10:33:00 pm</p><p><b>performer</b>: <a>Generated Summary: id: 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><blockquote><p><b>finding</b></p><h3>Items</h3><table><tr><td>-</td></tr><tr><td>*</td></tr></table></blockquote></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"
            }
          ]
        }
      }
    }
  ]
}