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Observation-example-abdo-tender

Example Observation/abdo-tender (Narrative)

Maturity Level : N/A
Responsible Owner: Orders and Observations Work Group Standards Status : Informative Compartments : Device , Encounter , Group , Patient , Practitioner , RelatedPerson

This is the narrative for the resource. See also the XML , JSON or Turtle format. This example conforms to the profile Observation .

Generated Narrative with Details Narrative: Observation abdo-tender

id : abdo-tender

status : final Final

category : Exam (Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'exam' = 'Exam', given as 'Exam'})

code : Abdominal tenderness (Details : {SNOMED CT code '43478001' = 'Abdominal tenderness', given as 'Abdominal tenderness (finding)'})

subject : Patient/example Jim Male, DoB: 1974-12-25 ( Medical record number (use: usual, period: 2001-05-06 --> (ongoing)))

encounter : Encounter/example Encounter: status = in-progress; class = inpatient encounter; subjectStatus = Receiving Care

effective : 02/04/2018 10:30:10 AM 2018-04-02T10:30:10+01:00 --> (ongoing)

issued : 03/04/2018 3:30:10 PM 2018-04-03T15:30:10+01:00

value : true Present

interpretation : Abnormal (Details : {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation code 'A' = 'Abnormal', given as 'Abnormal'})

 

 

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.