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Difference between revisions of "Clinicians on FHIR 2016 - January Orlando"
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=Care Plan Group= | =Care Plan Group= | ||
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'''Use Case''' | '''Use Case''' | ||
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Lead: Rob Hausam | Lead: Rob Hausam | ||
| − | https://global.gotomeeting.com/meeting/join/605884653 | + | GoToMeeting: https://global.gotomeeting.com/meeting/join/605884653 |
| − | '''Use Case''' | + | '''Background and Use Case''' |
| − | [[http://wiki.hl7.org/index.php?title=Observation_vs_Condition | Observation vs | + | [[http://wiki.hl7.org/index.php?title=Observation_vs_Condition | 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 | ||
Latest revision as of 14:20, 15 January 2016
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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
