PACIO Transitions of Care Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-transitions-of-care-ig/ and changes regularly. See the Directory of published versions
Page standards status: Informative |
Condition Asserted Date: 2024-04-18 13:30:00-0400
clinicalStatus: Active
verificationStatus: Confirmed
category: Encounter Diagnosis
code: Right hemiparesis (disorder)
bodySite: Right upper arm structure (body structure)
onset: 2024-04-17 15:40:00-0400
recordedDate: 2024-04-18 13:30:00-0400
asserter: PractitionerRole Neurology Physician
note:
Patient began experiencing right sided weakness, primarily in arm and shoulder. There was no facial droop, but patient reports "tingling" in R face / numbness along R brow. Symptoms in face resolved post tPA administration. Strength improved in shoulder, weakness did not fully resolve. Demonstrates R arm weakness and lack of coordination. Fine motor skills significantly degraded and have not improved post tPA.