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
| - | Code | Item |
| * | 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"
}
]
}
}
]
}