QI-Core Implementation Guide: STU Ballot (v3.3.0 for FHIR 4.0.0)
Quality Improvement Core Framework (v3.3.0: STU 4 Ballot 1). The current version is 3.2.0 based on FHIR R4. See the Directory of published versions
QDM defines Physical Exam as the evaluation of the patient's body and/or mental status exam to determine its state of health. The techniques of examination can include palpation (feeling with the hands or fingers), percussion (tapping with the fingers), auscultation (listening), visual inspection or observation, inquisition and smell. Measurements may include vital signs (blood pressure, pulse, respiration) as well as other clinical measures (such as expiratory flow rate and size of lesion). Physical exam includes psychiatric examinations.
US-Core defines a resources for vital signs (referencing the FHIR Vital Signs Profile), and two additional profiles – Pediatric-BMI-for Age and Pediatric Weight for Height. Other observations that meet the QDM definition of Physical Exam, Performed use the FHIR Observation resource
| QDM Context | QI-Core R4 | Comments |
| Physical Exam, Performed | Observation | |
| Observation.status | Constrain status to - final, amended, corrected | |
| Observation.category | Constrain to "exam" [Observations generated by physical exam findings including direct observations made by a clinician and use of simple instruments and the result of simple maneuvers performed directly on the patient's body.] | |
| QDM Attributes | ||
| code | Observation.code | |
| id | Observation.id | |
| method | Observation.method | |
| Observation.bodySite | ||
| relatedTo | Observation.basedOn | A plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed. |
| Observation.partOf | A larger event of which this particular Observation is a component or step. For example, an observation as part of a procedure. | |
| negation rationale | Observation.dataAbsentReason | |
| Observation.issued | Consider if authorDatetime (intended for negation rationale) fits with observation.issued or FHIR provenance for docuemtnation of the dataAbsentReason. | |
| reason | Observation.basedOn | the observation fulfills a plan, proposal or order - trace for authorization. Possibly not a fit for the intent in QDM (e.g., observation "reason" = a diagnosis) Is an extension needed? |
| result | Observation.value[x] | |
| Observation.interpretation | ||
| Relevant dateTime | Observation.effective[x] dateTime | |
| Relevant Period | Observation.effective[x] Period | |
| Author dateTime | Observation.issued | Consider if authorDatetime (intended for negation rationale) fits with observation.issued or FHIR provenance for docuemtnation of the dataAbsentReason. |
| Component | Observation.component | |
| Observation.component.id | ||
| Component code | Observation.component.code | |
| Component result | Observation.component.value[x] | |
| Observation.component.interpretation | ||
| Observation.component.dataAbsentReason | ||
| Performer | Observation.performer |
| QDM Context | QI-Core R4 | Comments |
| Physical Exam, Performed | Observation | Inherited from USCore R3 Pediatric Weight for Height |
| Observation.status | Constrain status to - final, amended, corrected | |
| Observation.category | ||
| QDM Attributes | ||
| code | Observation.code | |
| WtPercentile.code | ||
| id | Observation.code.id | |
| method | Observation.method | |
| relatedTo | Observation.basedOn | |
| negation rationale | Observation.dataAbsentReason | |
| Observation.issued | Consider if authorDatetime (intended for negation rationale) fits with observation.issued or FHIR provenance for docuemtnation of the dataAbsentReason. | |
| reason | Observation.basedOn | |
| result | Observation.valueQuantity | Quantity |
| Observation.interpretation | ||
| Relevant dateTime | Observation.effective[x] | |
| Relevant Period | Observation.effective[x] | |
| Author dateTime | Observation.issued | Consider if authorDatetime (intended for negation rationale) fits with observation.issued or FHIR provenance for docuemtnation of the dataAbsentReason. |
| Performer | Observation.performer |
| QDM Context | FHIR R4 | Link | Comments |
| Physical Exam, Performed | Vital Signs | VitalSigns | Inherited from FHIR R4 (as in USCore R3) |
| Vital Signs Panel | VitalsPanel | ||
| Observation.status | Observation.status | Constrain status to - final, amended, corrected | |
| QDM Attributes | |||
| code | VitalsPanel.code.code | VitalsPanelCode.code | 9279-1 |
| id | id (logical id of resource) | Observation.id | |
| method | Observation.method | Observation.method | |
| anatomic location site | Observation.bodySite | Observation.bodySite | |
| negation rationale | Observation.dataAbsentReason | Observation.dataAbsentReason | |
| reason | Observation.basedOn | Observation.basedOn | the observation fulfills a plan, proposal or order - trace for authorization. Possibly not a fit for the intent in QDM (e.g., observation "reason" = a diagnosis) Is an extension needed? |
| result | value[x] - Only used in component vitalsigns measurements | ||
| Relevant dateTime | Vitalspanel-definitions - Observation.effective[x] dateTime | Observation.effective[x] | |
| Relevant Period | Vitalspanel-definitions - Observation.effective[x] Period | Observation.effective[x] | |
| Author dateTime | Vitalspanel-definitions - Observation.issued | Observation.issued | Observation.issued is closer to reported time. Author dateTime is missing. |
| Reference Range High | Vitalspanel-definitions - Observation.referenceRange.high | Observation.referenceRange.high | |
| Reference Range Low | Vitals panel-definitions - Observation.referenceRange.low | Observation.referenceRange.low | |
| Component | Vitalspanel-definitions Observation.component | Observation.component | |
| Vitalspanel-definitions Component.id | Observation.component.id | ||
| Component Code | Observation.component.code | ||
| Component Result | Vitalspanel.Observation.component.value[x] | Observation.component.value[x] | |
| Vitalspanel.Observation.component dataAbsentReason | Observation.component.dataAbsentReason | ||
| Component reference range high | Vitalspanel.Observation.component.referenceRange | Observation.component.referenceRange | |
| Component reference range low | Vitalspanel.Observation.component.referenceRange | Observation.component.referenceRange | |
| Vitalspanel-definitions Observation.componentInterpretation | Observation.component.interpretation | ||
| Performer | Vitalspanel-definitions Observation.performer | Observation.performer | |
| Individual Vital Sign Observations | |||
| Respiratory Rate | Respiratory definition Observation | resprate | |
| ResprateCode.code | RespRateCode.code | LOINC | |
| Observation.value[x].code | Observation.value[x].code | UCUM | |
| Heart Rate | Heartrate definition | heartrate | |
| HeartrateCode.code | HeartRateCode.code | LOINC | |
| Observation.value[x].code | Observation.value[x] | UCUM | |
| Oxygen Saturation | Oxygensat definition | oxygensat | |
| OxygensatCode.code | OxygenSatCode.code | LOINC | |
| Observation.value[x].code | Observation.value[x].code | UCUM | |
| Body Tempurature | BodyTemp definition | http://hl7.org/fhir/R4/bodytemp.html | |
| BodyTempCode.code | BodyTempCode.code | LOINC | |
| Observation.value[x].code | Observation.value[x].code | UCUM | |
| Body Height | Bodyheight definition | http://hl7.org/fhir/R4/bodyheight.html | |
| BodyheightCode.code | BodyHeightCode.code | LOINC | |
| Observation.value[x].code | Observation.value[x].code | UCUM | |
| Head Circumference | Headcircum Definition | headcircum | |
| HeadcircumCode.code | HeadCircumCode.code | LOINC | |
| Observation.value[x].code | Observation.value[x].code | UCUM | |
| Body Weight | Bodyweight definition | bodyweight | |
| BodyweightCode.code | BodyWeightCode.code | LOINC | |
| Observation.value[x].code | Observation.value[x].code | UCUM | |
| Body Mass Index | bmi definition | bmi | |
| bmiCode.code | VSCat.coding.code | LOINC | |
| Observation.value[x].code | Observation.value[x].code | UCUM | |
| Blood Pressure Systolic and Diastolic | bp definition | bp | |
| bpCode.code | BPCode.code | LOINC | |
| Observation.value[x].code | Observation.component.value[x] | ||
| Systolic Blood Pressure (Component) | SystolicBP Component definition | http://hl7.org/fhir/R4/bp.html | |
| SPBCode.code | SystolicBP.code.coding:SBPCode.code | LOINC | |
| Observation.value[x].code | SystolicBP.valueQuantity.code | UCUM | |
| Diastollc Blood Pressure (Component) | DiastolicBP Component definition | bp | |
| DBPCode.code | DiastolicBP.code.coding:DBPCode.code | LOINC | |
| Observation.value[x].code | DiastolicBP.valueQuantity.code | UCUM |
To address the QDM attribute Physical Exam, Order see Service Request
To address the QDM attribute Physical Exam, Recommended see Service Request
© HL7.org 2011+. (Clinical Quality Improvement WG). hl7.fhir.us.qicore#3.3.0 based on FHIR v4.0.0 generated 06/08/2019.
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