QI-Core Implementation Guide
7.0.2 - STU 7

QI-Core Implementation Guide - Downloaded Version 7.0.2 See the Directory of published versions

## Example Observation: Observation example

Page standards status: Informative

Profile: QICore Simple Observation

Observation Body Position: Sitting position (finding)

status: Final

category: Vital Signs

code: Hemoglobin [Mass/volume] in Venous blood

subject: Jim Chalmers Male, DoB: 1974-12-25 ( Medical record number (use: usual, period: 2001-05-06 --> (ongoing)))

encounter: Encounter: status = in-progress; class = inpatient encounter (ActCode#IMP); type = Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.

effective: 2013-04-02 10:30:10+0100 --> 2013-04-05 10:30:10+0100

issued: 2013-04-03 15:30:10+0100

performer: Practitioner

value: 7.2 g/dl (Details: UCUM codeg/dL = 'g/dL')

interpretation: Below low normal

bodySite: Superficial forearm vein

method: Injection to forearm

derivedFrom: Observation Hemoglobin [Mass/volume] in Venous blood

> component

> code: Systolic blood pressure

> value: 107 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

> interpretation: Normal

> component

> code: Diastolic blood pressure

> value: 60 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

> interpretation: Below low normal