MedCom HomeCareObservation
1.1.0 - draft Denmark flag

MedCom HomeCareObservation, published by MedCom. This guide is not an authorized publication; it is the continuous build for version 1.1.0 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

Example DiagnosticReport: HomeCareDiagnosticReport:TOBS and ABC examination

Generated Narrative: DiagnosticReport efb1ed12-6a5d-4342-9572-861071644e46

HomeCareDiagnosticReport

SubjectElmer (official) (no stated gender), DoB Unknown ( urn:oid:1.2.208.176.1.2#2509479989)
Reported2023-09-12 12:24:19+0200
Performers Organization Pleje og Rehabilitering PractitionerRole Sygeplejerske

Report Details

CodeValueFlagsNoteWhen For
Pt—Respiration; frekvens = ? X 1/min19 1/minFinal, Not Interpreted2023-09-13 09:24:08+0200
Hjerte—Systole; frekv. = ? × 1/min92 1/minFinal, Not InterpretedPatienten har været ud og går lige inden målingen.2023-09-13 09:24:09+0200
Arm—Blodtryk(systolisk); tryk = ? mmHg147 mmHgFinal, Not Interpreted2023-09-13 09:24:10+0200
Pt—Bevidsthedsniveau; arb.antal(værdi 0-3) = ?0 1 (Details: UCUM code1 = '1')Final, Not Interpreted2023-09-13 09:24:11+0200
Pt—Legeme; temp. = ? °C38.7 °CFinal, Not Interpreted2023-09-13 09:24:12+0200
Pt—Tidlig Opsporing af Begyndende Sygdom (TOBS) score; antal (værdi 0-15) = ?3 1 (Details: UCUM code1 = '1')Final, Not Interpreted2023-09-13 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