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Difference between revisions of "Clinicians on FHIR 2016 - January Orlando"
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| Line 40: | Line 40: | ||
===History=== | ===History=== | ||
| + | *Headache | ||
| + | *The headache yesterday was the worst that she has ever had. | ||
| + | *No headache in the past 24 hours. | ||
===Physical Exam=== | ===Physical Exam=== | ||
| + | *Blood pressure 127/86 | ||
| + | *Deep tendon reflex 2+ - left knee | ||
| + | *Deep tendon reflex absent - right knee | ||
===Lab, Imaging and Other Results=== | ===Lab, Imaging and Other Results=== | ||
| − | + | *Serum Sodium = 137 (normal range 135-145) | |
| − | + | *Stool culture: No Salmonella, Shigella or Campylobacter isolated | |
| − | + | *Chest AP & lateral: Impression: Pneumonia in the right lower lobe. | |
| − | |||
Revision as of 13:32, 15 January 2016
Back to: Patient Care
Return to: FHIR Clinical Resources - PCWG
Return to: Clinicians on FHIR
Return to: Clinician on FHIR 2016
Contents
Introduction
Care Plan Group
Webex [1]
Use Case Care Plan DAM Story Board
Observation vs. Condition Group
Lead: Rob Hausam
Webex: 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: Pneumonia in the right lower lobe.
