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": "12/06/2014 09:00:00", "end": "12/06/2014 11:33:00" }, "date": "12/06/2014 11:33:00", "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" } ] } } ] }