Gives information about the Examination findings section
Important: The latest version of the PRSB documentation should be consulted for further information regarding Section headings and content http://theprsb.org
Examination Findings Section content
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. |
| 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
Coded Resources
This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.
- The ITK3 FHIR Outpatient Letter does not currently support coded examination findings.
