Clinicians on FHIR 2016 - January Orlando

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Care Plan Group

Use Case Care Plan DAM Story Board

Observation vs. Condition Group

Lead: Rob Hausam

GoToMeeting: https://global.gotomeeting.com/meeting/join/605884653

Background and Use Case [| Observation vs Condition]

ClinFhir Tool: http://clinfhir.com/

Tracking spreadsheet: https://docs.google.com/spreadsheets/d/1FCQayhXe5h9INy-b-KhtnDG0eZgDD29YMh1qBESYxPA/edit?usp=sharing

Example Observations (including negation/negative statements)

History

• Headache
• The headache yesterday was the worst that she has ever had.
• No headache in the past 24 hours.

Physical Exam

• Blood pressure 127/86
• Deep tendon reflex 2+ - left knee
• Deep tendon reflex absent - right knee

Lab, Imaging and Other Results

• Serum Sodium = 137 (normal range 135-145)
• Stool culture: No Salmonella, Shigella or Campylobacter isolated
• Chest AP & lateral: Impression: Evidence of pneumonia in the right lower lobe.

Assessment/Findings

• Right lower lobe pneumonia