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Clinicians on FHIR 2016 - January Orlando
Revision as of 14:20, 15 January 2016 by Rhausam (talk | contribs) (→Observation vs. Condition Group)
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Contents
Introduction
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
