Initial Assessment - Office Visit
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Contents |
[edit] Description
In the medical office setting, the initial assessment of a patient is typically completed by clinical staff of the primary provider. The data collected varies depending on type of practice and protocols used in each setting.
[edit] Synopsis
| Short Name | Initial Assessment |
|---|---|
| Long Name | Initial Assessment - Office Visit |
| TemplateID | |
| UMLS Concept Code | |
| Synonym | |
| Type | Observation |
| Revision | 11007 |
[edit] Applicability
| Account | eCHR/ePHR |
|---|---|
| Sex | All |
| Age | All |
| Exceptions | None |
[edit] Instructions
| Patient | N/A |
|---|---|
| Clinical | null |
[edit] Relationships
| Type | Category or CDD | Cardinality | Rule |
|---|---|---|---|
| Contains | Blood Pressure - Complete | 0..1 | |
| Contains | Respiration | 0..1 | |
| Contains | Temperature | 0..1 | |
| Contains | Pulse | 0..1 | |
| Contains | Weight | 0..1 | |
| Contains | Height | 0..1 | |
| Contains | Allergy | 0..1 | |
| Contains | Current Medications | 0..1 | |
| Contains | Current Vitamin or Mineral Supplements | 0..1 | |
| Contains | Last Menstrual Period | 0..1 |
[edit] Attributes
| Attribute | Value | Cardinality | Data Type |
|---|---|---|---|
| Not done because | Free Text | 0..1 | ED |
| Comments | Free Text | 0..1 | ED |
