ClinicalImpressionVitalSignsTriage
Introduction and scope
This profile is from the resource ClinicalImpression. The profile contains the registrations of vital data, triage, symptoms and contact causes as well as the notes from the screen pages Alarm data, Diagnosis, Notes and SAMPLES made by the ambulance rescuers. This brings together all clinical findings for the patient in one profile.
URL
https://PrehospitalDataInEHR.dk/fhir/StructureDefinition/RE01
Usage
In this profile there are seven elements. The element dentifier is mandatory. The element status is mandatory and its fixed value is set to registered, the element describing the status of the registration. The element subject contains a reference to the profile Patient, as all registrations in this profile must be tied up on the patient. Therefore, this element is also mandatory. In the same way, the element encounter contains a reference to the profile EncounterPrehospitalEncounter, as the collection of vital parameters, triage and cause of symptoms and contact is part of the consultation between patient and ambulance rescuer that EncounterPrehospitalEncounter describes. The collection of this information is essential for the consultation and the element is therefore also mandatory. The element effective ensures a timestamp to the profile and is mandatory. The element note contains the notes that the ambulance rescuer may make along the way and may contain remarks about the treatment, preliminary diagnosis and general notes. Therefore, this item is optional and sliced into four slices. The notes are tied up on the profile instead of being independent profiles, whereby all information about clinical findings is gathered in one profile. The element finding contains information about vital parameters, triage and cause of symptoms and contact. Therefore, this item is sliced into 19 slices. The vitaldata_bloodPressure slice has also been sliced once more, as both systolic and diastolic blood pressure must be registered. For each of the 19 slices, terminology bindings from SNOMED CT have been used, which are reviewed below, as some of the 19 slices do not fit one-to-one with respect to the description contained in the PPJ. For the slices not listed below,the SNOMED CT code matches the description in the PPJ.
- Slice contactReason_A: The slice represents symptom and contact cause A, where there are four registrations. A SNOMED CT code has been found for each of the four records. For the registration Potentially endangered airway use 397813008 | Respiratory trauma while using 125589001 | Traumatic upper respiratory tract injury for registration Respiratory injuries (fire, burns or trauma). For the registration Swelling of the lips and / or oral cavity is used 300878007 | Swelling in the oral cavity structure while using 301777002 | Swelling of the neck for registration Feeling of swollen throat.
- Slice contactReason_B: the slice represents symptom and contact cause B, where five registrations can be made. A SNOMED CT code has been found for each of the five registrations. The registration Does not breathe has a SNOMED CT code, while for the registration Severe shortness of breath has been used 230145002 | Difficulty breathing. For the registration Smoke inhalation in an enclosed space 426936004 | Traumatic inhalation injury caused by smoke, while 267036007 | Dyspnoea is used for the registration Moderate shortness of breath. For the last registration Exercise shortness of breath is used 60845006 | Dyspnoea on exertion.
- Slice contactReason_C: the slice represents symptom and contact cause C, where three registrations can be made. Four SNOMED CT codes have been found for the three registrations. Two SNOMED CT codes 131148009 | were used for the registration Bleeding despite compression Bleeding and 71173004 | Compression while recording Fresh bleeding "continuously" is covered by 112648003 | Massive bleeding. The registration Fresh bleeding "dripping" is covered by 8573003 | Acute bleeding.
- Slicet contactReason_D: slicet represents the registration symptom and contact cause, where 14 registrations can be made. 20 SNOMED CT codes have been found for the 14 registrations. For registration Severe pain is used 76948002 | Severe pain while registering Mild pain is covered by 40196000 | Mild pain. The code for 71587006 | Tetanic convulsions are used for the records Ongoing convulsions and Convulsions, now ceased. The registration Ceased seizures and known epilepsy are covered by 313307000 | Epileptic seizure, while 103018003 | Exertional dizziness is used for the registration Fainting on exertion. For registration Recurrent fainting cases, two SNOMED CT codes are used, namely 419045004 | Loss of consciousness and 407619008 | 2-4 seizures per month. The registration Exercise-triggered headache is covered by 230470007 | Episodic headache of tension type, while the registration Vision, balance, speech disorders or power loss, onset under 24 hours are covered by SNOMED CT codes for resp. 29164008 | Speech Disorder, 63102001 | Visual disturbance, 89419008 | Loss of balance and 162236007 | Power reduction found. For the registration Consciousness blur and abnormal blood sugar are used 102660008 | Abnormal glucose level and 40917007 | Blurred consciousness while registering Blurred consciousness and normal blood sugar are covered by 102659003 | Normal glucose level and 40917007 | Blurred consciousness. The three remaining records have SNOMED CT codes that match their description.
- Slice contactReason_E: the slice represents registration of symptom and contact cause E, where a registration can be made. A SNOMED CT code has been used for the registration. For the registration Acute decreased sense of touch on the extremity has been used 310501001 | Numbness in extremities.
- Slice contactReason_K: the slice represents registrations of symptom and contact cause K, where four registrations can be made. Four SNOMED CT codes have been used for the four registrations. For the registration Exposure to dangerous substances is used 129231000119103 | Exposure to potentially hazardous chemical (event). For the remaining three registrations, SNOMED CT codes match the descriptions in the PPJ.
- Slice triage: this slice uses all the vital data parameters to determine the patient's triage. Therefore, these values are reused and the triage contains an additional SNOMED CT code for 273887006 | Triage index.
- Slice vitaldata_bloodPressure: this slice represents the registration of blood pressure, where two registrations can be made. For registration Systolic blood pressure is used 271649006 | Systolic blood pressure while recording Diastolic blood pressure 271650006 | Diastolic blood pressure.
- Slice vitaldata_heartRhythmType: slices represent the recording of the patient's heart rhythm, where 12 recordings can be made. 12 SNOMED CT codes have been used for the 112 registrations. For the 11 registrations there are appropriate SNOMED CT codes, but for the registration Block configuration use 164898000 | ECG: heart block.
XML code for ClinicalImpressionVitalSignsTriage
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