Examination Findings Element Documentation

Overview

Examination Findings elements represent results from physical examinations and clinical assessments performed by healthcare providers during patient encounters.

Function

builder.add_examination_finding(
    code: CodeInput,
    value: Optional[str] = None,
    date: Optional[DateTimeInput] = None,
    status: Union[ObservationStatus, str] = "final",
    notes: Optional[str] = None,
    id: Optional[str] = None,
) -> Observation

Parameters

Required Parameters

• code: The examination type or body system examined

Optional Parameters

• value: The examination findings or result
• date: When the examination was performed
• status: Observation status (default: “final”)
• notes: Additional details about the examination
• id: Custom resource ID

Basic Usage

Simple Examination (Preferred with CodeableConcept)

from fhir_sdk import FHIRDocumentBuilder
from fhir_sdk.types import create_codeable_concept

builder = FHIRDocumentBuilder()
builder.add_patient(name="John Doe", age=30)
builder.add_encounter()

# Add examination finding
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Heart sounds",
        code="364080008",
        system="http://snomed.info/sct",
        display="Heart sounds"
    ),
    value="Normal S1 and S2, no murmurs"
)

Using String (Alternative)

exam = builder.add_examination_finding(
    code="Heart sounds",
    value="Normal S1 and S2, no murmurs"
)

Detailed Examination with Notes

from datetime import datetime

exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Abdominal examination",
        code="271870009",
        system="http://snomed.info/sct"
    ),
    value="Soft, non-tender, no masses palpated",
    date=datetime.now(),
    notes="Patient cooperative throughout examination"
)

Common Physical Examinations

Cardiovascular System

# Heart sounds
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Heart sounds",
        code="364080008",
        system="http://snomed.info/sct"
    ),
    value="Regular rate and rhythm, no murmurs"
)

# Peripheral pulses
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Peripheral pulses",
        code="43685005",
        system="http://snomed.info/sct"
    ),
    value="All pulses palpable and equal bilaterally"
)

Respiratory System

# Lung sounds
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Lung sounds",
        code="28914005",
        system="http://snomed.info/sct"
    ),
    value="Clear to auscultation bilaterally"
)

# Chest wall inspection
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Chest wall examination",
        code="364088001",
        system="http://snomed.info/sct"
    ),
    value="Symmetric expansion, no retractions"
)

Gastrointestinal System

# Abdominal examination
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Abdominal examination",
        code="271870009",
        system="http://snomed.info/sct"
    ),
    value="Soft, non-distended, bowel sounds present"
)

# Liver examination
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Liver palpation",
        code="64453007",
        system="http://snomed.info/sct"
    ),
    value="Not enlarged, no tenderness"
)

Neurological System

# Mental status
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Mental status examination",
        code="314548002",
        system="http://snomed.info/sct"
    ),
    value="Alert and oriented x 3"
)

# Reflexes
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Deep tendon reflexes",
        code="87572000",
        system="http://snomed.info/sct"
    ),
    value="2+ and symmetric throughout"
)

# Cranial nerves
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Cranial nerve examination",
        code="280151006",
        system="http://snomed.info/sct"
    ),
    value="Cranial nerves II-XII grossly intact"
)

Musculoskeletal System

# Joint examination
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Joint examination",
        code="309542004",
        system="http://snomed.info/sct"
    ),
    value="Full range of motion, no swelling or deformity"
)

# Muscle strength
exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Muscle strength testing",
        code="271590003",
        system="http://snomed.info/sct"
    ),
    value="5/5 strength in all extremities"
)

Skin Examination

exam = builder.add_examination_finding(
    code=create_codeable_concept(
        text="Skin examination",
        code="274181009",
        system="http://snomed.info/sct"
    ),
    value="Warm, dry, intact. No rashes or lesions noted"
)

Abnormal Findings

Positive Findings

exam = builder.add_examination_finding(
    code="Lymph node examination",
    value="Palpable lymph nodes in neck",
    notes="Bilateral cervical lymphadenopathy, mobile, non-tender"
)

Negative Findings (Rule-outs)

exam = builder.add_examination_finding(
    code="Neck stiffness assessment",
    value="No meningeal signs",
    notes="Full range of motion, no nuchal rigidity"
)

Examination Status Options

from fhir_sdk import ObservationStatus

# Preliminary examination
exam = builder.add_examination_finding(
    code="Initial assessment",
    value="Appears stable",
    status=ObservationStatus.PRELIMINARY
)

# Final examination
exam = builder.add_examination_finding(
    code="Complete physical exam",
    value="Within normal limits",
    status=ObservationStatus.FINAL
)

Time-based Examinations

from datetime import datetime

# Examination during current encounter
exam = builder.add_examination_finding(
    code="General appearance",
    value="Well-appearing, in no acute distress",
    date=datetime.now()
)

Regional Examinations

Head and Neck

exam = builder.add_examination_finding(
    code="Head and neck examination",
    value="HEENT: PERRL, EOM intact, throat clear, no lymphadenopathy"
)

Extremities

exam = builder.add_examination_finding(
    code="Extremity examination",
    value="No clubbing, cyanosis, or edema. Capillary refill <2 seconds"
)

Best Practices

1. Use create_codeable_concept with SNOMED CT codes for standardized examinations
2. Provide descriptive findings rather than just “normal” or “abnormal”
3. Include both positive and negative (rule-out) findings
4. Document examination date for temporal context
5. Use consistent terminology for similar findings
6. Include relevant anatomical details and severity
7. Note patient cooperation or limitations affecting examination

Common Examination Values

• Normal findings: “Within normal limits”, “No abnormalities detected”
• Cardiovascular: “Regular rate and rhythm”, “No murmurs”
• Respiratory: “Clear to auscultation”, “Equal air entry”
• Abdominal: “Soft, non-tender”, “Bowel sounds present”
• Neurological: “Alert and oriented”, “No focal deficits”
• Musculoskeletal: “Full range of motion”, “No deformity”

Notes

• Examination findings are categorized as “exam” observations
• Findings should be objective and descriptive
• Multiple examinations can comprehensively document physical assessment
• Date/time helps establish examination sequence during encounters
• Detailed findings support clinical decision-making and care planning