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Example Observation/2minute-apgar-score (XML)

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Raw XML (canonical form + also see XML Format Specification)

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Example of a 2 minute Apgar score with individual score as components (id = "2minute-apgar-score")

<?xml version="1.0" encoding="UTF-8"?>

<Observation xmlns="http://hl7.org/fhir">
  <id value="2minute-apgar-score"/> 
      <!--     Using a contained patient for the purposes of this example Observation.  Typically
   the reference would be to an external resource     -->
  <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative: Observation</b> <a name="2minute-apgar-score"> </a> <a name="hc2minute-apgar-score"> </a> </p> <div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border:
       1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Observation &quot;2minute-apgar-score&quot; </p> </div> <p> <b> status</b> : final</p> <p> <b> category</b> : Survey <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.5.0/CodeSystem-observation-category.html">Observation Category Codes</a> #survey)</span> </p> <p> <b> code</b> : 2 minute Apgar Score <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a> #9273-4)</span> </p> <p> <b> subject</b> : <a name="hcnewborn"> </a> </p> <blockquote> <p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;"><b> Peter James Chalmers </b>  male, DoB: 2016-05-18 ( <code> http://acmehealthcare/org/mrns</code> /12345)</p> <hr/>  <table class="grid"><tr> <td style="background-color: #f3f5da" title="Record is active">Active:</td> <td colspan="3">true</td> </tr> </table> </blockquote> <p> <b> effective</b> : 2016-05-18T22:33:22Z</p> <p> <b> performer</b> : <a href="practitioner-example.html">Practitioner/example</a>  &quot;Adam CAREFUL&quot;</p> <p> <b> value</b> : 5 {score}<span style="background: LightGoldenRodYellow"> (Details: UCUM code {score} = '{score}')</span> </p> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar color score <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a> #249227004)</span> </p> <p> <b> value</b> : 1. Good color in body with bluish hands or feet <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a> #LA6723-6 &quot;Good color in body with bluish hands or feet&quot;; apgarcolor#1)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a> #249223000 &quot;Apgar heart rate score&quot;)</span> </p> <p> <b> value</b> : 1. Fewer than 100 beats per minute <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a> #LA6717-8 &quot;Fewer than 100 beats per minute&quot;; apgarheartrate#1)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar response to stimulus score <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a> #249226008)</span> </p> <p> <b> value</b> : 1. Grimace during suctioning <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a> #LA6721-0 &quot;Grimace and pulling away, cough, or sneeze during suctioning&quot;;
             apgarreflexirritability#1)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar muscle tone score <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a> #249225007)</span> </p> <p> <b> value</b> : 1. Some flexion of arms and legs <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a> #LA6714-5 &quot;Some flexion of arms and legs&quot;; apgarmuscletone#1)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a> #249224006)</span> </p> <p> <b> value</b> : 1. Weak cry; may sound like whimpering, slow or irregular breathing <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a> #LA6726-9 &quot;Weak cry; may sound like whimpering, slow or irregular breathing&quot;;
             apgarrespiratoryeffort#1)</span> </p> </blockquote> <hr/>  <blockquote> <p> <b> Generated Narrative: Patient #newborn</b> <a name="newborn"> </a> <a name="hcnewborn"> </a> </p> <p> <b> identifier</b> : <span title="    MRN assigned by ACME healthcare on    "><code> http://acmehealthcare/org/mrns</code> /12345</span> </p> <p> <b> active</b> : true</p> <p> <b> name</b> : <span title="    Peter James Chalmers    ">Peter James Chalmers </span> </p> <p> <b> gender</b> : <span title="    use FHIR code system for male / female    ">male</span> </p> <p> <b> birthDate</b> : 2016-05-18</p> </blockquote> </div> </text> <contained> 
    <Patient> 
      <id value="newborn"/> 
          <!--      MRN assigned by ACME healthcare on      -->
      <identifier> 
        <system value="http://acmehealthcare/org/mrns"/> 
        <value value="12345"/> 
      </identifier> 
      <active value="true"/> 
          <!--      Peter James Chalmers      -->
      <name> 
        <family value="Chalmers"/> 
        <given value="Peter"/> 
        <given value="James"/> 
      </name> 
          <!--      use FHIR code system for male / female      -->
      <gender value="male"/> 
      <birthDate value="2016-05-18">
        <extension url="http://hl7.org/fhir/StructureDefinition/patient-birthTime">
          <valueDateTime value="2016-05-18T10:28:45Z"/> 
        </extension> 
      </birthDate> 
    </Patient> 
  </contained> 
  <status value="final"/> 
  <category> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/observation-category"/> 
      <code value="survey"/> 
      <display value="Survey"/> 
    </coding> 
    <text value="Survey"/> 
  </category> 
  <code> 
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="9273-4"/> 
      <display value="2 minute Apgar Score"/> 
    </coding> 
    <text value="2 minute Apgar Score"/> 
  </code> 
  <subject> 
    <reference value="#newborn"/> 
  </subject> 
  <effectiveDateTime value="2016-05-18T22:33:22Z"/> 
  <performer> 
    <reference value="Practitioner/example"/> 
  </performer> 
  <valueQuantity> 
    <value value="5"/> 
    <system value="http://unitsofmeasure.org"/> 
    <code value="{score}"/> 
  </valueQuantity> 
  <component> 
    <code> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="249227004"/> 
        <display value="Apgar color score"/> 
      </coding> 
      <text value="Apgar color score"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
            <!--   this  extension  maps a numeric score to the code this may already be known and
         unecessary   -->
        <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight">
          <valueDecimal value="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6723-6"/> 
        <display value="Good color in body with bluish hands or feet"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarcolor"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Good color in body with bluish hands or feet"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="249223000"/> 
        <display value="Apgar heart rate score"/> 
      </coding> 
      <text value="Apgar respiratory effort score"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
            <!--   this  extension  maps a numeric score to the code this may already be known and
         unecessary   -->
        <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight">
          <valueDecimal value="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6717-8"/> 
        <display value="Fewer than 100 beats per minute"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarheartrate"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Fewer than 100 beats per minute"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="249226008"/> 
        <display value="Apgar response to stimulus score"/> 
      </coding> 
      <text value="Apgar response to stimulus score"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
            <!--   this  extension  maps a numeric score to the code this may already be known and
         unecessary   -->
        <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight">
          <valueDecimal value="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6721-0"/> 
        <display value="Grimace and pulling away, cough, or sneeze during suctioning"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarreflexirritability"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Grimace during suctioning"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="249225007"/> 
        <display value="Apgar muscle tone score"/> 
      </coding> 
      <text value="Apgar muscle tone score"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
            <!--   this  extension  maps a numeric score to the code this may already be known and
         unecessary   -->
        <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight">
          <valueDecimal value="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6714-5"/> 
        <display value="Some flexion of arms and legs"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarmuscletone"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Some flexion of arms and legs"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="249224006"/> 
        <display value="Apgar respiratory effort score"/> 
      </coding> 
      <text value="Apgar respiratory effort score"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
            <!--   this  extension  maps a numeric score to the code this may already be known and
         unecessary   -->
        <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight">
          <valueDecimal value="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6726-9"/> 
        <display value="Weak cry; may sound like whimpering, slow or irregular breathing"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarrespiratoryeffort"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Weak cry; may sound like whimpering, slow or irregular breathing"/> 
    </valueCodeableConcept> 
  </component> 
</Observation> 

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.