Patient
Physical examination
General findings and detailed examination by system.
Format definition
Use observations for findings, with collection, availability, interpretation, and disclosure separated.
Scenario standard · Execution capabilities
Parameters
observations[].id
string
Optional; omitted means unspecified
Stable finding or measurement identity; a repeat collection creates a new observation ID.
observations[].patientId
string
Optional; omitted means unspecified
Patient to whom the observation belongs.
observations[].code
string
Optional; omitted means unspecified
Namespaced concept, such as usim:general-appearance; codes do not imply external terminology certification.
observations[].kind
"symptom" | "finding" | "measurement"
Optional; omitted means unspecified
Separates reported experience, observed findings, and measured values.
observations[].status
"known"
Optional; omitted means unspecified
Known requires a value. Other statuses prohibit a value rather than using zero or an empty string as a sentinel.
observations[].value
number
Optional; omitted means unspecified
Type must match the registered concept. Qualitative findings can be text or explicit booleans.
observations[].unit
string
Optional; omitted means unspecified
Fixed by the concept definition; no inferred conversions.
observations[].collectedAtSeconds
number
Optional; omitted means unspecified
Time of authored assessment or acquisition, possibly before baseline.
observations[].availableAtSeconds
number
Optional; omitted means unspecified
Earliest simulated time for release; disclosure conditions must also be satisfied.
observations[].method
string
Optional; omitted means unspecified
Method, location, or equipment used to obtain the finding.
observations[].disclosure
object
Optional; omitted means unspecified
Select one of the declared Disclosure alternatives; use the fields belonging to that alternative.
Behavior and validation
- Author-selected normal findings use usim:age-based-normal-findings@1.1.0 in authoringProfiles. Select by age in years: infant [0,1), child [1,12), adolescent [12,18), adult [18,65), older adult [65,infinity); missing or invalid age uses age-neutral text. Materialize selected text as explicit authored observations linked to the system. Preserve existing values, including blanks, unknown and not assessed. Age changes never rewrite saved findings. Omission never implies normal; do not inject templates during import or playback. Selected templates are stored as canonical observations: symptom entries for ROS and finding entries for examination, linked by patientId and system code.
- Pending results do not expose their future value in learner outputs. Underlying authored values and runtime release status must remain distinct.
- A numeric concept has one declared unit and value type in the profile. New concepts require definitions under extensions until standardized.
Shared format conventions · All format elements · Download specification