Pengiriman Data Hasil Pemeriksaan Fisik

Setelah sesi anamnesis, dokter akan melakukan beberapa pemeriksaan fisik. Data hasil pemeriksaan fisik dapat dikirimkan melalui resource Observation.

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

TIPS

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.

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Pemeriksaan Fisik - Vital Sign

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
Observation.valueQuantity.code	/min

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
Observation.valueQuantity.code	/min

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
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
Observation.valueQuantity.code	mm[Hg]

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
Observation.valueQuantity.code	Cel

Pemeriksaan Fisik - Tingkat Kesadaran

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

Pemeriksaan Fisik Head to Toe (Bagian 1)

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)

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)

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)

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)

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)

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)

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)

Pemeriksaan Fisik Head to Toe (Bagian 2)

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)

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	Physical findings of Mouth and Throat and Teeth Narrative
Observation.bodySite.coding.system	http://snomed.info/sct
Observation.bodySite.coding.code	72914001
Observation.bodySite.coding.display	Palatal structure
Observation.valueString	(Tipe data String)

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)

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)

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)

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)

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)