When a patient has an encounter with a doctor, nurse or surgeon, Observations are usually made. What does this look like in the real world?
A patient, Bruno Holtzmann, visits his GP complaining of a strong acidic taste in his mouth each morning.
As Bruno answers the doctor’s specific questions, his answers are recorded as Observations in FHIR.
She takes Bruno’s blood pressure. Another Observation.
Listens to his heart. Another Observation.
The doctor suspects acid reflux and updates Bruno’s record. This is represented by a Condition resource in FHIR, with all relevant Observations from the examination connected to it.
She refers Bruno to a gastroenterologist for an endoscopy, and two weeks later Bruno goes to his local hospital for the procedure.
His blood pressure is taken again, as is his temperature. More Observations.
Bruno chooses not to be sedated. Another Observation.
The procedure begins and the endoscope starts taking pictures.
The doctor documents findings as she looks at the images. More Observations.
A couple of specimens are taken from Bruno’s oesophagus and sent off to the lab for analysis. The lab runs their tests and records Observations.
At the end of the procedure the doctor documents in detail what she found, collecting all the Observations together to diagnose a Condition and produce a DiagnosticReport.
All of these Observations made over a number of weeks connect to the patient record by way of the initial encounter at the GP surgery, the pre-procedure encounter with the nurses at the hospital, the Procedure itself, and the post-procedure findings made in the pathology lab.
In terms of data stored, Observation is one of the most important and versatile of all FHIR resources.
Learn more here: http://hl7.org/fhir/R4/observation.html
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