# Pengiriman Data Hasil Pemeriksaan Fisik

Setelah sesi anamnesis, dokter akan melakukan beberapa pemeriksaan fisik. Data hasil pemeriksaan fisik dapat dikirimkan melalui resource [Observation](https://www.hl7.org/fhir/observation.html).

Pelajari resource observation dan element-elementnya secara lengkap pada bagian Resource & Terminologi:

{% content-ref url="broken-reference" %}
[Broken link](https://dokumentasisatusehat-stg.dto.kemkes.go.id/modul-interoperabilitas/rawat-jalan/broken-reference)
{% endcontent-ref %}

{% hint style="success" %} <mark style="color:green;">**TIPS**</mark>

Setiap element menggunakan terminologi yang berbeda sesuai dengan data kesehatan yang akan dikirimkan. Perhatikan bahwa terminologi dapat mengacu pada terminologi secara general (berlaku untuk semua modul) ataupun terminologi spesifik (berlaku untuk modul tertentu).

Perhatikan keterangan elemen terkait pada bagian Resource & Elemen.
{% endhint %}

***

### Pemeriksaan Fisik - Vital Sign

{% tabs %}
{% tab title="Denyut Jantung" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | vital-signs                                                  |
| Observation.category\[i].coding\[i].display | Vital Signs                                                  |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 8867-4                                                       |
| Observation.code.coding.display             | Heart rate                                                   |
| Observation.valueQuantity.value             | (Tipe data Decimal)                                          |
| Observation.valueQuantity.unit              | beats/min                                                    |
| Observation.valueQuantity.system            | [http://unitsofmeasure.org](http://unitsofmeasure.org/)      |
| Observation.valueQuantity.code              | /min                                                         |
| {% endtab %}                                |                                                              |

{% tab title="Pernapasan " %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | vital-signs                                                  |
| Observation.category\[i].coding\[i].display | Vital Signs                                                  |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 9279-1                                                       |
| Observation.code.coding.display             | Respiratory rate                                             |
| Observation.valueQuantity.value             | (Tipe data Decimal)                                          |
| Observation.valueQuantity.unit              | breaths/min                                                  |
| Observation.valueQuantity.system            | [http://unitsofmeasure.org](http://unitsofmeasure.org/)      |
| Observation.valueQuantity.code              | /min                                                         |
| {% endtab %}                                |                                                              |

{% tab title="Tekanan Darah" %}
Sistole

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | vital-signs                                                  |
| Observation.category\[i].coding\[i].display | Vital Signs                                                  |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 8480-6                                                       |
| Observation.code.coding.display             | Systolic blood pressure                                      |
| Observation.valueQuantity.value             | (Tipe data Decimal)                                          |
| Observation.valueQuantity.unit              | mm\[Hg]                                                      |
| Observation.valueQuantity.system            | [http://unitsofmeasure.org](http://unitsofmeasure.org/)      |
| Observation.valueQuantity.code              | mm\[Hg]                                                      |

**Diastole**

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | vital-signs                                                  |
| Observation.category\[i].coding\[i].display | Vital Signs                                                  |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 8462-4                                                       |
| Observation.code.coding.display             | Diastolic blood pressure                                     |
| Observation.valueQuantity.value             | (Tipe data Decimal)                                          |
| Observation.valueQuantity.unit              | mm\[Hg]                                                      |
| Observation.valueQuantity.system            | [http://unitsofmeasure.org](http://unitsofmeasure.org/)      |
| Observation.valueQuantity.code              | mm\[Hg]                                                      |

{% endtab %}

{% tab title="Suhu Tubuh" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | vital-signs                                                  |
| Observation.category\[i].coding\[i].display | Vital Signs                                                  |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 8310-5                                                       |
| Observation.code.coding.display             | Body temperature                                             |
| Observation.valueQuantity.value             | (Tipe data Decimal)                                          |
| Observation.valueQuantity.unit              | C                                                            |
| Observation.valueQuantity.system            | [http://unitsofmeasure.org](http://unitsofmeasure.org/)      |
| Observation.valueQuantity.code              | Cel                                                          |
| {% endtab %}                                |                                                              |
| {% endtabs %}                               |                                                              |

### Pemeriksaan Fisik - Tingkat Kesadaran

{% tabs %}
{% tab title="Tingkat Kesadaran" %}

| Elemen                                  | Nilai Elemen                                                 |
| --------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding.system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding.code    | exam                                                         |
| Observation.category\[i].coding.display | Exam                                                         |
| \*Observation.code.coding.system        | <http://loinc.org>                                           |
| \*Observation.code.coding.code          | 67775-7                                                      |
| \*Observation.code.coding.display       | Level of responsiveness                                      |

**Ketentuan Data Tingkat Kesadaran:**

| Observation.valueCodeableConcept\[i].coding.system | Observation.valueCodeableConcept\[i].coding.code | Observation.valueCodeableConcept\[i].coding.display | Keterangan                                       |
| -------------------------------------------------- | ------------------------------------------------ | --------------------------------------------------- | ------------------------------------------------ |
| <http://snomed.info/sct>                           | 248234008                                        | Mentally alert                                      | 1. Sadar Baik/Alert: 0                           |
| <http://snomed.info/sct>                           | 300202002                                        | Response to voice                                   | 2. Berespon dengan kata-kata/Voice: 1            |
| <http://snomed.info/sct>                           | 450847001                                        | Responds to pain                                    | 3. Hanya berespons jika dirangsang nyeri/pain: 2 |
| <http://snomed.info/sct>                           | 422768004                                        | Unresponsive                                        | 4. Pasien tidak sadar/unresponsive: 3            |
| <http://snomed.info/sct>                           | 130987000                                        | Acute confusion                                     | 5. Gelisah atau bingung: 4                       |
| <http://snomed.info/sct>                           | 2776000                                          | Delirium                                            | 6. Acute Confusional States: 5                   |
| {% endtab %}                                       |                                                  |                                                     |                                                  |
| {% endtabs %}                                      |                                                  |                                                     |                                                  |

### Pemeriksaan Fisik Head to Toe (Bagian 1)

{% tabs %}
{% tab title="Kepala" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 10199-8                                                      |
| Observation.code.coding.display             | Physical findings of Head Narrative                          |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |

{% tab title="Mata" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 10197-2                                                      |
| Observation.code.coding.display             | Physical findings of Eye Narrative                           |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |

{% tab title="Telinga" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 10195-6                                                      |
| Observation.code.coding.display             | Physical findings of Ear Narrative                           |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |

{% tab title="Hidung" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 10203-8                                                      |
| Observation.code.coding.display             | Physical findings of Nose Narrative                          |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |

{% tab title="Rambut" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 32436-8                                                      |
| Observation.code.coding.display             | Physical findings of Hair                                    |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |

{% tab title="Bibir" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 32446-7                                                      |
| Observation.code.coding.display             | Physical findings of Lip                                     |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |

{% tab title="Gigi Geligi" %}

| Elemen                                      | Elemen                                                       |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 85910-8                                                      |
| Observation.code.coding.display             | Physical findings of Teeth and Gum Narrative                 |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |
| {% endtabs %}                               |                                                              |

### Pemeriksaan Fisik Head to Toe (Bagian 2)

{% tabs %}
{% tab title="Lidah" %}

| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 32483-0                                                      |
| Observation.code.coding.display             | Physical findings of Tongue                                  |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |

{% tab title="Langit-langit" %}

| Elemen                                      | Nilai Elemen                                                                    |
| ------------------------------------------- | ------------------------------------------------------------------------------- |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category>                    |
| Observation.category\[i].coding\[i].code    | exam                                                                            |
| Observation.category\[i].coding\[i].display | Exam                                                                            |
| Observation.code.coding.system              | <http://loinc.org>                                                              |
| Observation.code.coding.code                | 10201-2                                                                         |
| Observation.code.coding.display             | <p>Physical findings of Mouth and Throat and Teeth Narrative</p><p><br><br></p> |
| Observation.bodySite.coding.system          | <http://snomed.info/sct>                                                        |
| Observation.bodySite.coding.code            | 72914001                                                                        |
| Observation.bodySite.coding.display         | Palatal structure                                                               |
| Observation.valueString                     | (Tipe data String)                                                              |
| {% endtab %}                                |                                                                                 |

{% tab title="Leher" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 11411-6                                                      |
| Observation.code.coding.display             | Physical findings of Neck Narrative                          |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |

{% tab title="Tenggorokan" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 56867-5                                                      |
| Observation.code.coding.display             | Physical findings of Throat Narrative                        |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |

{% tab title="Tonsil" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 10201-2                                                      |
| Observation.code.coding.display             | Physical findings of Mouth and Throat and Teeth Narrative    |
| Observation.bodySite.coding.system          | <http://snomed.info/sct>                                     |
| Observation.bodySite.coding.code            | 91636008                                                     |
| Observation.bodySite.coding.display         | Bilateral palatine tonsils                                   |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |

{% tab title="Dada" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 11391-0                                                      |
| Observation.code.coding.display             | Physical findings of Chest Narrative                         |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |

{% tab title="Payudara" %}

| Elemen                                      | Nilai Elemen                                                 |
| ------------------------------------------- | ------------------------------------------------------------ |
| Observation.category\[i].coding\[i].system  | <http://terminology.hl7.org/CodeSystem/observation-category> |
| Observation.category\[i].coding\[i].code    | exam                                                         |
| Observation.category\[i].coding\[i].display | Exam                                                         |
| Observation.code.coding.system              | <http://loinc.org>                                           |
| Observation.code.coding.code                | 10193-1                                                      |
| Observation.code.coding.display             | Physical findings of Breasts Narrative                       |
| Observation.valueString                     | (Tipe data String)                                           |
| {% endtab %}                                |                                                              |
| {% endtabs %}                               |                                                              |