MedCom HomeCareObservation
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This page is part of the The DK MedCom HomeCareObservation (v1.0.0: Release) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

: Modified HomeCareDiagnosticReport:TOBS and ABC examination - JSON Representation

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{
  "resourceType" : "DiagnosticReport",
  "id" : "cfa9e95b-b5ac-4cfe-abe7-ea29e6b67919",
  "meta" : {
    "profile" : [
      "http://medcomfhir.dk/ig/homecareobservation/StructureDefinition/medcom-homecare-diagnosticreport"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h2><span title=\"Codes: {http://medcomfhir.dk/ig/terminology/CodeSystem/MedComDiagnosticReportCodes HomeCareReport}\">HomeCareDiagnosticReport</span> </h2><table class=\"grid\"><tr><td>Subject</td><td><b>Elmer (OFFICIAL)</b> (no stated gender), DoB Unknown ( id:\u00a02509479989)</td></tr><tr><td>Reported</td><td>2023-09-12 12:34:00+0200</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><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><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><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><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><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><span title=\"Codes: \">NI</span></td><td/><td>2023-09-13 09:24:13+0200</td></tr></table><p>\r\nABCDE\r\nSeFølLyt-Princippet\r\nA.\tRF 19 – påskyndet men regelmæssig, fri respiration. SAT 93%\r\nB.\tPuls 92 palperet på venstre håndled. Fyldig regelmæssig. Fin kapilærrespons\r\nC.\tBT 147/83 – klamtsvedende. Kolde ekstremiteter. \r\nD.\tReagerer habituelt. Pupilreaktion i.a. VAS 7. Bl.s. 6,8\r\nE.\tTemperatur 38,7 Målt rektalt\r\n\r\n\r\nPatienten har nægtet at spise og drikke i løbet af dagen. \r\n</p></div>"
  },
  "status" : "corrected",
  "code" : {
    "coding" : [
      {
        "system" : "http://medcomfhir.dk/ig/terminology/CodeSystem/MedComDiagnosticReportCodes",
        "code" : "HomeCareReport"
      }
    ]
  },
  "subject" : {
    "reference" : "Patient/bbcd4817-1c4b-4089-a712-346f65ec16f9"
  },
  "issued" : "2023-09-12T12:34:00+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" : "\r\nABCDE\r\nSeFølLyt-Princippet\r\nA.\tRF 19 – påskyndet men regelmæssig, fri respiration. SAT 93%\r\nB.\tPuls 92 palperet på venstre håndled. Fyldig regelmæssig. Fin kapilærrespons\r\nC.\tBT 147/83 – klamtsvedende. Kolde ekstremiteter. \r\nD.\tReagerer habituelt. Pupilreaktion i.a. VAS 7. Bl.s. 6,8\r\nE.\tTemperatur 38,7 Målt rektalt\r\n\r\n\r\nPatienten har nægtet at spise og drikke i løbet af dagen. \r\n"
}