Ejemplo


Texto :

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)


json :

{
    "resourceType": "ClinicalImpression",
    "id": "example",
    "text": {
        "status": "generated",
        --- We have skipped the narrative for better readability of the resource ---
    },
    "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"
    },
    "context": {
        "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"
                    }
                ]
            }
        }
    ]
}