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Packagemedcom.fhir.dk.homecareobservation
Resource TypeDiagnosticReport
IdDiagnosticReport-cfa9e95b-b5ac-4cfe-abe7-ea29e6b67919.json
FHIR VersionR4

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Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: DiagnosticReport cfa9e95b-b5ac-4cfe-abe7-ea29e6b67919

HomeCareDiagnosticReport

SubjectElmer (official) (no stated gender), DoB Unknown ( urn:oid:1.2.208.176.1.2#2509479989)
Reported2023-09-12 12:34:00+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 Interpreted

Patienten 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 Patienten har nægtet at spise og drikke i løbet af dagen.

Source1

{
  "resourceType": "DiagnosticReport",
  "id": "cfa9e95b-b5ac-4cfe-abe7-ea29e6b67919",
  "meta": {
    "profile": [
      "http://medcomfhir.dk/ig/homecareobservation/StructureDefinition/medcom-homecareobservation-diagnosticreport"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "status": "final",
  "code": {
    "coding": [
      {
        "system": "http://medcomfhir.dk/ig/terminology/CodeSystem/MedComDiagnosticReportCodes",
        "code": "HomeCareReport"
      }
    ]
  },
  "subject": {
    "reference": "Patient/bbcd4817-1c4b-4089-a712-346f65ec16f9"
  },
  "issued": "2023-09-12T12:34:00+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": "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\n\n\nPatienten har nægtet at spise og drikke i løbet af dagen."
}