If you have an issue with this template then please raise an issue in Simplifier against this IG by using the 'Propose a Change' link in the footer
Examination findings
The Examination findings section carries about the examination and any findings. PRSB Elements should be formatted as subheadings in any HTML sent.
| Section | Description | Card. | MRO* | FHIR Target and Guidance |
|---|---|---|---|---|
| Examination finding | The record of findings from clinical examination. | 0 to 1 | O | Carried in the CodeableConcept of Composition.section.code FHIR element. ValueSet UKCoreCompositionSectionCode |
| PRSB Element | Description | Card. | MRO* | FHIR Target and Guidance |
| Examination | This could include site and must include laterality where applicable. | 0 to 1 | O | Carried as text only, this is the record of the examinations undertaken during the appointment. The examination performed, eg general appearance, vital signs, mental state, head and neck examination, oral examination, cardiovascular system, respiratory system, abdomen, genitourinary, nervous system, musculoskeletal system, skin. |
| Examination findings | The record of findings from the examinations performed. | 0 to 1 | O | This is the record of clinically relevant findings from the examinations undertaken during the appointment. Text only. |
| * M=Mandatory R=Required O=Optional | ||||
Example Examination Findings Section
This section is not used in the Hackathon examples. Refer to other sections for example. The section text / section.code (ValueSet UKCoreCompositionSectionCode) and any linked coded resources applicable to the section would differ. e.
Example Coded Resources
Refer to National Pathology IG. A UKCore-Observation with member UKCore-Observation(s).