JanuSync Implementation Guide - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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: DaType2HospHomeNursingClinicalImpressionExample - XML Representation

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<ClinicalImpression xmlns="http://hl7.org/fhir">
  <id value="DaType2HospHomeNursingClinicalImpressionExample"/>
  <meta>
    <profile
             value="http://connectdtx.kr/fhir/StructureDefinition/janusync-home-nursing-clinical-impression"/>
  </meta>
  <status value="completed"/>
  <code>
    <coding>
      <system
              value="http://example.org/fhir/CodeSystem/clinical-impression-type"/>
      <code value="home-nursing-assessment"/>
      <display value="Home nursing assessment"/>
    </coding>
    <text value="가정간호 평가"/>
  </code>
  <subject>🔗 
    <reference value="Patient/janusync-deidentified-patient-example"/>
  </subject>
  <encounter>
    <reference value="Encounter/home-nursing-encounter-example"/>
  </encounter>
  <effectiveDateTime value="2026-04-14T14:30:00+09:00"/>
  <date value="2026-04-14T14:45:00+09:00"/>
  <assessor>🔗 
    <reference
               value="PractitionerRole/janusync-medicaldoctor-practitionerrole-example"/>
  </assessor>
  <finding>
    <itemCodeableConcept>
      <coding>
        <system
                value="http://connectdtx.kr/fhir/CodeSystem/janusync-observation-component"/>
        <code value="home-visit.vital"/>
        <display value="방문 시 활력징후 요약"/>
      </coding>
      <text value="방문 시 활력징후 요약"/>
    </itemCodeableConcept>
    <basis
           value="혈압 118/76 mmHg, 맥박 78회/분, 체온 36.7도, 산소포화도 96%로 전반적으로 안정적임."/>
  </finding>
  <finding>
    <itemCodeableConcept>
      <coding>
        <system
                value="http://connectdtx.kr/fhir/CodeSystem/janusync-observation-component"/>
        <code value="home-visit.assessment"/>
        <display value="방문 평가 내용"/>
      </coding>
      <text value="방문 평가 내용"/>
    </itemCodeableConcept>
    <basis value="호흡 상태 및 전반적 컨디션이 안정적이며 보호자 보고상 최근 분비물 증가 등 특이사항 없음."/>
  </finding>
  <finding>
    <itemCodeableConcept>
      <coding>
        <system
                value="http://connectdtx.kr/fhir/CodeSystem/janusync-observation-component"/>
        <code value="home-visit.intervention"/>
        <display value="방문 중재 내용"/>
      </coding>
      <text value="방문 중재 내용"/>
    </itemCodeableConcept>
    <basis value="기도흡인 수행법과 튜브 연결 상태를 재교육하고 체위 변경 및 분비물 관리 방법을 안내함."/>
  </finding>
  <finding>
    <itemCodeableConcept>
      <coding>
        <system
                value="http://connectdtx.kr/fhir/CodeSystem/janusync-observation-component"/>
        <code value="home-visit.outcome"/>
        <display value="방문 후 경과"/>
      </coding>
      <text value="방문 후 경과"/>
    </itemCodeableConcept>
    <basis value="방문 후 호흡곤란 악화 소견 없으며 보호자도 이해도 양호하여 다음 방문 전까지 현재 관리 유지 예정."/>
  </finding>
  <supportingInfo>🔗 
    <reference
               value="Observation/DaType2HospVentilatorCheckObservationExample"/>
  </supportingInfo>
</ClinicalImpression>