MedCom HomeCareObservation
1.1.0 - draft
MedCom HomeCareObservation
1.1.0 - draft
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
{
"resourceType" : "DiagnosticReport",
"id" : "efb1ed12-6a5d-4342-9572-861071644e46",
"meta" : {
"profile" : [
🔗 "http://medcomfhir.dk/ig/homecareobservation/StructureDefinition/medcom-homecareobservation-diagnosticreport"
]
},
"text" : {
"status" : "generated",
"div" : "<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:{http://medcomfhir.dk/ig/terminology/CodeSystem/medcom-observation-codes MCS88122}\">Pt—Respiration; frekvens = ? X 1/min</span></a></td><td>19 1/min</td><td>Final, <span title=\"Codes:{http://medcomfhir.dk/ig/terminology/CodeSystem/medcom-core-interpretation-codes NI}\">Not Interpreted</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:{http://medcomfhir.dk/ig/terminology/CodeSystem/medcom-core-interpretation-codes NI}\">Not Interpreted</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:{http://medcomfhir.dk/ig/terminology/CodeSystem/medcom-core-interpretation-codes NI}\">Not Interpreted</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:{http://medcomfhir.dk/ig/terminology/CodeSystem/medcom-observation-codes MCS88126}\">Pt—Bevidsthedsniveau; arb.antal(værdi 0-3) = ?</span></a></td><td>0 1<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code1 = '1')</span></td><td>Final, <span title=\"Codes:{http://medcomfhir.dk/ig/terminology/CodeSystem/medcom-core-interpretation-codes NI}\">Not Interpreted</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:{http://medcomfhir.dk/ig/terminology/CodeSystem/medcom-core-interpretation-codes NI}\">Not Interpreted</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:{http://medcomfhir.dk/ig/terminology/CodeSystem/medcom-observation-codes MCS88125}\">Pt—Tidlig Opsporing af Begyndende Sygdom (TOBS) score; antal (værdi 0-15) = ?</span></a></td><td>3 1<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code1 = '1')</span></td><td>Final, <span title=\"Codes:{http://medcomfhir.dk/ig/terminology/CodeSystem/medcom-core-interpretation-codes NI}\">Not Interpreted</span></td><td/><td>2023-09-13 09:24:13+0200</td></tr></table><p>ABCDE\nSeFølLyt-Princippet\nA.\tRF 19 - påskyndet men regelmæssig, fri respiration. SAT 93%\nB.\tPuls 92 palperet på venstre håndled. Fyldig regelmæssig. Fin kapilærrespons\nC.\tBT 147/83 - klamtsvedende. Kolde ekstremiteter. \nD.\tReagerer habituelt. Pupilreaktion i.a. VAS 7. Bl.s. 6,8\nE.\tTemperatur 38,7 Målt rektalt</p></div>"
},
"status" : "final",
"code" : {
"coding" : [
{
"system" : "http://medcomfhir.dk/ig/terminology/CodeSystem/MedComDiagnosticReportCodes",
"code" : "HomeCareReport"
}
]
},
"subject" : {
🔗 "reference" : "Patient/bbcd4817-1c4b-4089-a712-346f65ec16f9"
},
"issued" : "2023-09-12T12:24:19+02:00",
"performer" : [
{
🔗 "reference" : "Organization/a0330c62-fe29-4719-83fa-a94959084f29"
},
{
🔗 "reference" : "PractitionerRole/4b3b6f0f-a475-4b04-8a92-105e8ce6a7bf"
}
],
"result" : [
{
🔗 "reference" : "Observation/3fd3835d-1758-4d22-8547-000182752817"
},
{
🔗 "reference" : "Observation/ba691ee4-6d38-4f5b-82f1-40b54e3b8ad1"
},
{
🔗 "reference" : "Observation/8917f29d-269c-4bb3-8ce9-d255c351d52b"
},
{
🔗 "reference" : "Observation/6bf03841-8397-4a2a-9f9a-8966b0cfa571"
},
{
🔗 "reference" : "Observation/85fd1372-cf02-49c6-bd45-7205f5541a66"
},
{
🔗 "reference" : "Observation/f64a0a78-53cf-4a7f-9b89-4a2338a4935c"
}
],
"conclusion" : "ABCDE\nSeFølLyt-Princippet\nA.\tRF 19 - påskyndet men regelmæssig, fri respiration. SAT 93%\nB.\tPuls 92 palperet på venstre håndled. Fyldig regelmæssig. Fin kapilærrespons\nC.\tBT 147/83 - klamtsvedende. Kolde ekstremiteter. \nD.\tReagerer habituelt. Pupilreaktion i.a. VAS 7. Bl.s. 6,8\nE.\tTemperatur 38,7 Målt rektalt"
}