MedCom HomeCareObservation
1.0.0 - release Denmark flag

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

: HomeCareDiagnosticReport:TOBS and ABC examination - XML Representation

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<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="efb1ed12-6a5d-4342-9572-861071644e46"/>
  <meta>
    <profile
             value="http://medcomfhir.dk/ig/homecareobservation/StructureDefinition/medcom-homecare-diagnosticreport"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: DiagnosticReport efb1ed12-6a5d-4342-9572-861071644e46</b></p><a name="efb1ed12-6a5d-4342-9572-861071644e46"> </a><a name="hcefb1ed12-6a5d-4342-9572-861071644e46"> </a><a name="efb1ed12-6a5d-4342-9572-861071644e46-da-DK"> </a><h2><span title="Codes:{http://medcomfhir.dk/ig/terminology/CodeSystem/MedComDiagnosticReportCodes HomeCareReport}">HomeCareDiagnosticReport</span> </h2><table class="grid"><tr><td>Subject</td><td>Elmer (official) (no stated gender), DoB Unknown ( urn:oid:1.2.208.176.1.2#2509479989)</td></tr><tr><td>Reported</td><td>2023-09-12 12:24:19+0200</td></tr><tr><td>Performers</td><td> <a href="Organization-a0330c62-fe29-4719-83fa-a94959084f29.html">Organization Pleje og Rehabilitering</a> <a href="PractitionerRole-4b3b6f0f-a475-4b04-8a92-105e8ce6a7bf.html">PractitionerRole Sygeplejerske</a></td></tr></table><p><b>Report Details</b></p><table class="grid"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Flags</b></td><td><b>Note</b></td><td><b>When For</b></td></tr><tr><td><a href="Observation-3fd3835d-1758-4d22-8547-000182752817.html"><span title="Codes:{https://terminology.medcom.dk/fhir/observation-code MCS88122}">Pt—Respiration; frekvens = ? X 1/min</span></a></td><td>19 1/min</td><td>Final, <span title="Codes:">NI</span></td><td/><td>2023-09-13 09:24:08+0200</td></tr><tr><td><a href="Observation-ba691ee4-6d38-4f5b-82f1-40b54e3b8ad1.html"><span title="Codes:{urn:oid:1.2.208.176.2.1 NPU21692}">Hjerte—Systole; frekv. = ? × 1/min</span></a></td><td>92  1/min</td><td>Final, <span title="Codes:">NI</span></td><td>Patienten har været ud og går lige inden målingen.</td><td>2023-09-13 09:24:09+0200</td></tr><tr><td><a href="Observation-8917f29d-269c-4bb3-8ce9-d255c351d52b.html"><span title="Codes:{urn:oid:1.2.208.176.2.1 DNK05472}">Arm—Blodtryk(systolisk); tryk = ? mmHg</span></a></td><td>147 mmHg</td><td>Final, <span title="Codes:">NI</span></td><td/><td>2023-09-13 09:24:10+0200</td></tr><tr><td><a href="Observation-6bf03841-8397-4a2a-9f9a-8966b0cfa571.html"><span title="Codes:{https://terminology.medcom.dk/fhir/observation-code MCS88126}">Pt—Bevidsthedsniveau; arb.antal(værdi 0-3) = ?</span></a></td><td>0</td><td>Final, <span title="Codes:">NI</span></td><td/><td>2023-09-13 09:24:11+0200</td></tr><tr><td><a href="Observation-85fd1372-cf02-49c6-bd45-7205f5541a66.html"><span title="Codes:{urn:oid:1.2.208.176.2.1 NPU08676}">Pt—Legeme; temp. = ? °C</span></a></td><td>38.7 °C</td><td>Final, <span title="Codes:">NI</span></td><td/><td>2023-09-13 09:24:12+0200</td></tr><tr><td><a href="Observation-f64a0a78-53cf-4a7f-9b89-4a2338a4935c.html"><span title="Codes:{https://terminology.medcom.dk/fhir/observation-code MCS88125}">Pt—Tidlig Opsporing af Begyndende Sygdom (TOBS) score; antal (værdi 0-15) = ?</span></a></td><td>3</td><td>Final, <span title="Codes:">NI</span></td><td/><td>2023-09-13 09:24:13+0200</td></tr></table><p>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 </p></div>
  </text>
  <status value="final"/>
  <code>
    <coding>
      <system
              value="http://medcomfhir.dk/ig/terminology/CodeSystem/MedComDiagnosticReportCodes"/>
      <code value="HomeCareReport"/>
    </coding>
  </code>
  <subject>🔗 
    <reference value="Patient/bbcd4817-1c4b-4089-a712-346f65ec16f9"/>
  </subject>
  <issued value="2023-09-12T12:24:19+02:00"/>
  <performer>🔗 
    <reference value="Organization/a0330c62-fe29-4719-83fa-a94959084f29"/>
  </performer>
  <performer>🔗 
    <reference value="PractitionerRole/4b3b6f0f-a475-4b04-8a92-105e8ce6a7bf"/>
  </performer>
  <result>🔗 
    <reference value="Observation/3fd3835d-1758-4d22-8547-000182752817"/>
  </result>
  <result>🔗 
    <reference value="Observation/ba691ee4-6d38-4f5b-82f1-40b54e3b8ad1"/>
  </result>
  <result>🔗 
    <reference value="Observation/8917f29d-269c-4bb3-8ce9-d255c351d52b"/>
  </result>
  <result>🔗 
    <reference value="Observation/6bf03841-8397-4a2a-9f9a-8966b0cfa571"/>
  </result>
  <result>🔗 
    <reference value="Observation/85fd1372-cf02-49c6-bd45-7205f5541a66"/>
  </result>
  <result>🔗 
    <reference value="Observation/f64a0a78-53cf-4a7f-9b89-4a2338a4935c"/>
  </result>
  <conclusion
              value="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 "/>
</DiagnosticReport>