MedCom HomeCareObservation
1.0.0 - release
MedCom HomeCareObservation
1.0.0 - release
MedCom HomeCareObservation, published by MedCom. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/medcomdk/dk_HomeCareObservations/ and changes regularly. See the Directory of published versions
Generated Narrative: DiagnosticReport cfa9e95b-b5ac-4cfe-abe7-ea29e6b67919
| Subject | Elmer (official) (no stated gender), DoB Unknown ( urn:oid:1.2.208.176.1.2#2509479989) |
| Reported | 2023-09-12 12:34:00+0200 |
| Performers | Organization Pleje og Rehabilitering PractitionerRole Sygeplejerske |
Report Details
| Code | Value | Flags | Note | When For |
| Pt—Respiration; frekvens = ? X 1/min | 19 1/min | Final, NI | 2023-09-13 09:24:08+0200 | |
| Hjerte—Systole; frekv. = ? × 1/min | 92 1/min | Final, NI | Patienten har været ud og går lige inden målingen. | 2023-09-13 09:24:09+0200 |
| Arm—Blodtryk(systolisk); tryk = ? mmHg | 147 mmHg | Final, NI | 2023-09-13 09:24:10+0200 | |
| Pt—Bevidsthedsniveau; arb.antal(værdi 0-3) = ? | 0 | Final, NI | 2023-09-13 09:24:11+0200 | |
| Pt—Legeme; temp. = ? °C | 38.7 °C | Final, NI | 2023-09-13 09:24:12+0200 | |
| Pt—Tidlig Opsporing af Begyndende Sygdom (TOBS) score; antal (værdi 0-15) = ? | 3 | Final, NI | 2023-09-13 09:24:13+0200 |
ABCDE SeFølLyt-Princippet A. RF 19 – påskyndet men regelmæssig, fri respiration. SAT 93% B. Puls 92 palperet på venstre håndled. Fyldig regelmæssig. Fin kapilærrespons C. BT 147/83 – klamtsvedende. Kolde ekstremiteter. D. Reagerer habituelt. Pupilreaktion i.a. VAS 7. Bl.s. 6,8 E. Temperatur 38,7 Målt rektalt Patienten har nægtet at spise og drikke i løbet af dagen.