AU Core Implementation Guide
0.1.0-draft - Draft Australia flag

This page is part of the AU Core Implementation Guide 0.1.0 Draft. It is based on AU Base 4.1.0. For a full list of available versions, see the Directory of published versions

Example Encounter: Encounter - presentation at GP for nail wound

Page standards status: Informative

Generated Narrative: Encounter

Resource Encounter "nailwound"

Profile: AU Core Encounter

Encounter Description: Patient presented with open injury to sole of left foot caused by stepping on rusty nail yesterday. Wound red and swollen, no calf muscle tenderness, no coughing nor chest pain which excludes pulmonary embolism. Patient has an existing allergy to adhesive tape, which manifests as urticaria. Patient was given booster dose of anti tetanus and prescribed amoxicillin 500mg 3 times a day. Wound was attended. Advised to present in 2 days to the usual GPs clinic for a change of dressings.

status: finished

class: ambulatory (Details: http://terminology.hl7.org/CodeSystem/v3-ActCode code AMB = 'ambulatory', stated as 'ambulatory')

type: Patient-initiated encounter (SNOMED CT#270427003)

serviceType: General practice service (SNOMED CT#788007007)

subject: Patient/wang-li " WANG"

Participants

-TypeIndividual
*primary performer (ParticipationType#PPRF)PractitionerRole/bobrester-bob-gp

period: 2017-03-31 15:20:00+1000 --> 2017-03-31 15:40:00+1000

reasonCode: Nail wound of sole of foot (SNOMED CT#283680004)

reasonReference: Condition/nailwound