Combining related data to one diagnostic report

1

Hi, there’re total 4 parts in my stroke report,

1. Patient Information (done)

  • “Patient” to store the basic information
  • “Encounter” for doctor info , period info(admission and discharge) and a basic diagnostic (using “Condition” and put it under Encounter)

2. Quality record
Including:

  1. Details about the admission to a hospital (period from patient had seizure to hospital)
  2. Period details like the period of Brain CT time, period of consulting time, ICH/HH and their score of evaluation. also record the delay reason.
  3. Details about the patient (is he/she smoking or being rehabilitation)

3. Emergency Care (done)

  • “Procedure” to store all the info. like (period of OP, category of OP)

4. Consciousness record x 4 (done)

  • “DiagnosticReport” to store different “Observation” (like the verbal response or pupil size)

My questions are

  1. I am struggling in the second part, not sure which recourses I should use to store all the quality record.
  2. Is it possible to combine all the forms(data) to one “DiagnosticReport” ? if not what is your suggestion?

Thank you!

2

DiagnoticReport is typically used as a response to an imaging or lab order, not as a summary of everything that happened during an encounter. If you really need a ‘report’, you might consider a FHIR document.

The stuff in #2 seems like it would mostly fall under Observation.

3

Thank you Lloyd
So I am going to use “Observation” to store the data in Quality record.
Actually I am not understanding the meaning of “FHIR document”, would you mind telling me more please

4

You can see more about FHIR documents here: Documents - FHIR v4.6.0

1 Like