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Narrative

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Source1

{
  "resourceType": "Observation",
  "id": "ma-ma-schema-1-Observation-clinical-note-5006",
  "meta": {
    "lastUpdated": "2023-12-18T23:07:47Z",
    "source": "urn:telus:emr:ma:ma-schema-1",
    "security": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
        "code": "N",
        "display": "normal"
      }
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "identifier": [
    {
      "use": "official",
      "system": "urn:telus:emr:ma:ma-schema-1:Observation",
      "value": "clinical-5006"
    }
  ],
  "status": "final",
  "category": [
    {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/observation-category",
          "code": "exam",
          "display": "Exam"
        }
      ]
    }
  ],
  "code": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "404684003",
        "display": "Clinical finding"
      }
    ],
    "text": "Physical Examination Note"
  },
  "subject": {
    "reference": "Patient/ma-ma-schema-1-Patient-12345",
    "type": "Patient",
    "display": "John Michael Smith"
  },
  "encounter": {
    "reference": "Encounter/ma-ma-schema-1-Encounter-2001",
    "type": "Encounter"
  },
  "effectiveDateTime": "2023-12-18T10:20:00Z",
  "performer": [
    {
      "reference": "Practitioner/ma-ma-schema-1-Practitioner-789",
      "type": "Practitioner",
      "display": "Dr. Sarah Johnson"
    }
  ],
  "note": [
    {
      "authorReference": {
        "reference": "Practitioner/ma-ma-schema-1-Practitioner-789"
      },
      "time": "2023-12-18T10:20:00Z",
      "text": "Patient presents for annual physical examination. General appearance: well-developed, well-nourished. HEENT: normocephalic, atraumatic. Cardiovascular: regular rate and rhythm, no murmurs. Respiratory: clear to auscultation bilaterally. Abdomen: soft, non-tender, non-distended. Extremities: no edema. Neurological: alert and oriented x3, cranial nerves II-XII intact. Skin: no rashes or lesions noted. Overall assessment: healthy adult in good general health."
    }
  ],
  "bodySite": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "38266002",
        "display": "Entire body as a whole"
      }
    ]
  }
}