QI-Core Implementation Guide: STU 4 (v4.0.0 for FHIR 4.0.0)

QI-Core Implementation Guide, Clinical Quality Improvement WG - CI build for vesion 4.0.0). This version is based on the current content of https://github.com/cqframework/qi-core/ and changes regularly. See the Directory of published versions

7.19.0 Physical Exam

  • Removal of the "method" attribute from "Physical Exam, Order" and "Physical Exam, Recommended"

QDM defines Physical Exam as the evaluation of the patient's body and/or mental status exam to determine its state of health. The techniques of examination can include palpation (feeling with the hands or fingers), percussion (tapping with the fingers), auscultation (listening), visual inspection or observation, inquisition and smell. Measurements may include vital signs (blood pressure, pulse, respiration) as well as other clinical measures (such as expiratory flow rate and size of lesion). Physical exam includes psychiatric examinations.

US-Core defines a resources for vital signs (referencing the FHIR Vital Signs Profile), and two additional profiles – Pediatric-BMI-for Age and Pediatric Weight for Height. Other observations that meet the QDM definition of Physical Exam, Performed use the FHIR Observation resource

7.19.1 Physical Exam, Performed: General

QDM Context QI-Core R4 Comments
Physical Exam, Performed Observation
Observation.status Constrain status to - final, amended, corrected
Observation.category Constrain to "exam" [Observations generated by physical exam findings including direct observations made by a clinician and use of simple instruments and the result of simple maneuvers performed directly on the patient's body.]
QDM Attributes
code Observation.code
id Observation.id
method Observation.method
Observation.bodySite
relatedTo Observation.basedOn A plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed.
Observation.partOf A larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure.
negation rationale Observation.dataAbsentReason
Observation.issued Consider if authorDatetime (intended for negation rationale) fits with observation.issued or FHIR provenance for docuemtnation of the dataAbsentReason.
reason Observation.basedOn the observation fulfills a plan, proposal or order - trace for authorization. Possibly not a fit for the intent in QDM (e.g., observation "reason" = a diagnosis) Is an extension needed?
result Observation.value[x]
Observation.interpretation
Relevant dateTime Observation.effective[x] dateTime
Relevant Period Observation.effective[x] Period
Author dateTime Observation.issued Consider if authorDatetime (intended for negation rationale) fits with observation.issued or FHIR provenance for docuemtnation of the dataAbsentReason.
Component Observation.component
Observation.component.id
Component code Observation.component.code
Component result Observation.component.value[x]
Observation.component.interpretation
Observation.component.dataAbsentReason
Performer Observation.performer

7.19.2 Physical Exam, Performed - Pediatric Weight for Height

QDM Context QI-Core R4 Comments
Physical Exam, Performed Observation Inherited from USCore R3 Pediatric Weight for Height
Observation.status Constrain status to - final, amended, corrected
Observation.category
QDM Attributes
code Observation.code
WtPercentile.code
id Observation.code.id
method Observation.method
relatedTo Observation.basedOn
negation rationale Observation.dataAbsentReason
Observation.issued Consider if authorDatetime (intended for negation rationale) fits with observation.issued or FHIR provenance for docuemtnation of the dataAbsentReason.
reason Observation.basedOn
result Observation.valueQuantity Quantity
Observation.interpretation
Relevant dateTime Observation.effective[x]
Relevant Period Observation.effective[x]
Author dateTime Observation.issued Consider if authorDatetime (intended for negation rationale) fits with observation.issued or FHIR provenance for docuemtnation of the dataAbsentReason.
Performer Observation.performer

7.19.3 Physical Exam, Performed - Pediatric BMI for Age

QDM Context USCore R3 Comments
Physical Exam, Performed Observation
Observation.status Constrain status to - final, amended, corrected
Observation.category
QDM Attributes
code Observation.code
BMIPercentile.code LOINC
id Observation.id
method Observation.method
relatedTo Observation.basedOn
negation rationale Observation.dataAbsentReason
Observation.issued Consider if authorDatetime (intended for negation rationale) fits with observation.issued or FHIR provenance for docuemtnation of the dataAbsentReason.
reason Observation.basedOn
result Observation.value[x] Quantity
Observation.value[x].code %
Observation.interpretation
Relevant dateTime Observation.effective[x]
Relevant Period Observation.effective[x]
Author dateTime Observation.issued Consider if authorDatetime (intended for negation rationale) fits with observation.issued or FHIR provenance for docuemtnation of the dataAbsentReason.
Performer Observation.performer

7.19.4 Physical Exam, Performed - Vital Signs

QDM Context FHIR R4 Link Comments
Physical Exam, Performed Vital Signs VitalSigns Inherited from FHIR R4 (as in USCore R3)
Vital Signs Panel VitalsPanel
Observation.status Observation.status Constrain status to - final, amended, corrected
QDM Attributes
code VitalsPanel.code.code VitalsPanelCode.code 9279-1
id id (logical id of resource) Observation.id
method Observation.method Observation.method
anatomic location site Observation.bodySite Observation.bodySite
negation rationale Observation.dataAbsentReason Observation.dataAbsentReason
reason Observation.basedOn Observation.basedOn the observation fulfills a plan, proposal or order - trace for authorization. Possibly not a fit for the intent in QDM (e.g., observation "reason" = a diagnosis) Is an extension needed?
result value[x] - Only used in component vitalsigns measurements
Relevant dateTime Vitalspanel-definitions - Observation.effective[x] dateTime Observation.effective[x]
Relevant Period Vitalspanel-definitions - Observation.effective[x] Period Observation.effective[x]
Author dateTime Vitalspanel-definitions - Observation.issued Observation.issued Observation.issued is closer to reported time. Author dateTime is missing.
Reference Range High Vitalspanel-definitions - Observation.referenceRange.high Observation.referenceRange.high
Reference Range Low Vitals panel-definitions - Observation.referenceRange.low Observation.referenceRange.low
Component Vitalspanel-definitions Observation.component Observation.component
Vitalspanel-definitions Component.id Observation.component.id
Component Code Observation.component.code
Component Result Vitalspanel.Observation.component.value[x] Observation.component.value[x]
Vitalspanel.Observation.component dataAbsentReason Observation.component.dataAbsentReason
Component reference range high Vitalspanel.Observation.component.referenceRange Observation.component.referenceRange
Component reference range low Vitalspanel.Observation.component.referenceRange Observation.component.referenceRange
Vitalspanel-definitions Observation.componentInterpretation Observation.component.interpretation
Performer Vitalspanel-definitions Observation.performer Observation.performer
Individual Vital Sign Observations
Respiratory Rate Respiratory definition Observation resprate
ResprateCode.code RespRateCode.code LOINC
Observation.value[x].code Observation.value[x].code UCUM
Heart Rate Heartrate definition heartrate
HeartrateCode.code HeartRateCode.code LOINC
Observation.value[x].code Observation.value[x] UCUM
Oxygen Saturation Oxygensat definition oxygensat
OxygensatCode.code OxygenSatCode.code LOINC
Observation.value[x].code Observation.value[x].code UCUM
Body Tempurature BodyTemp definition http://hl7.org/fhir/R4/bodytemp.html
BodyTempCode.code BodyTempCode.code LOINC
Observation.value[x].code Observation.value[x].code UCUM
Body Height Bodyheight definition http://hl7.org/fhir/R4/bodyheight.html
BodyheightCode.code BodyHeightCode.code LOINC
Observation.value[x].code Observation.value[x].code UCUM
Head Circumference Headcircum Definition headcircum
HeadcircumCode.code HeadCircumCode.code LOINC
Observation.value[x].code Observation.value[x].code UCUM
Body Weight Bodyweight definition bodyweight
BodyweightCode.code BodyWeightCode.code LOINC
Observation.value[x].code Observation.value[x].code UCUM
Body Mass Index bmi definition bmi
bmiCode.code VSCat.coding.code LOINC
Observation.value[x].code Observation.value[x].code UCUM
Blood Pressure Systolic and Diastolic bp definition bp
bpCode.code BPCode.code LOINC
Observation.value[x].code Observation.component.value[x]
Systolic Blood Pressure (Component) SystolicBP Component definition http://hl7.org/fhir/R4/bp.html
SPBCode.code SystolicBP.code.coding:SBPCode.code LOINC
Observation.value[x].code SystolicBP.valueQuantity.code UCUM
Diastollc Blood Pressure (Component) DiastolicBP Component definition bp
DBPCode.code DiastolicBP.code.coding:DBPCode.code LOINC
Observation.value[x].code DiastolicBP.valueQuantity.code UCUM

7.19.5 Physical Exam, Order

To address the QDM attribute Physical Exam, Order see Service Request

7.19.6 Physical Exam, Recommended

To address the QDM attribute Physical Exam, Recommended see Service Request