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Observation-example-glasgow-qa.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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Clinical assessment tool example - GCS with individual scores as related QuestionnaireAnswer (id = "gcs-qa")

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

<Observation xmlns="http://hl7.org/fhir">
  <id value="gcs-qa"/> <!--     the mandatory quality flags:     --><text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : gcs-qa</p> <p> <b> status</b> : final</p> <p> <b> code</b> : Glasgow Coma Scale , (GCS) <span> (Details : {LOINC code '9269-2' = 'Glasgow coma score total', given as 'Glasgow coma score
           total'})</span> </p> <p> <b> subject</b> : <a> Peter James Chalmers</a> </p> <p> <b> effective</b> : Dec 11, 2014 4:44:16 AM</p> <p> <b> value</b> : 13 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <blockquote> <p> <b> referenceRange</b> </p> <p> <b> high</b> : 8 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> type</b> : Severe TBI <span> (Details )</span> </p> </blockquote> <blockquote> <p> <b> referenceRange</b> </p> <p> <b> low</b> : 9 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> high</b> : 12 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> type</b> : Moderate TBI <span> (Details )</span> </p> </blockquote> <blockquote> <p> <b> referenceRange</b> </p> <p> <b> low</b> : 13 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> type</b> : Mild TBI <span> (Details )</span> </p> </blockquote> <p> <b> derivedFrom</b> : <a> GCS form results</a> </p> </div> </text> <status value="final"/> <!--    
    Observations are often coded in multiple code systems.
      - LOINC
    - or SNOMED
      -and/or the source system may provides its own "local" code, which may be less or
   more granular than LOINC.
  In this example there is only LOINC
      --><code> <!--     LOINC - always recommended to have a LOINC code     --><coding> 
      <system value="http://loinc.org"/> 
      <code value="9269-2"/> 
      <display value="Glasgow coma score total"/> 
    </coding> 
    <text value="Glasgow Coma Scale , (GCS)"/> 
  </code> 
  <subject> 
    <reference value="Patient/example"/> 
    <display value="Peter James Chalmers"/> 
  </subject> 
  <effectiveDateTime value="2014-12-11T04:44:16Z"/> <!--     In FHIR, units may be represented twice. Once in the
    agreed human representation, and once in a coded form.
    In this example the UCUM unit is provided but no human representation since this is
   often not displayed
       --><valueQuantity> 
    <value value="13"/> 
    <system value="http://unitsofmeasure.org"/> 
    <code value="{score}"/> 
  </valueQuantity> 
  <referenceRange> 
    <high> 
      <value value="8"/> 
      <system value="http://unitsofmeasure.org"/> 
      <code value="{score}"/> 
    </high> <!--     meaning as text     --><type> 
      <text value="Severe TBI"/> 
    </type> 
  </referenceRange> 
  <referenceRange> 
    <low> 
      <value value="9"/> 
      <system value="http://unitsofmeasure.org"/> 
      <code value="{score}"/> 
    </low> 
    <high> 
      <value value="12"/> 
      <system value="http://unitsofmeasure.org"/> 
      <code value="{score}"/> 
    </high> <!--     meaning as text     --><type> 
      <text value="Moderate TBI"/> 
    </type> 
  </referenceRange> 
  <referenceRange> 
    <low> 
      <value value="13"/> 
      <system value="http://unitsofmeasure.org"/> 
      <code value="{score}"/> 
    </low> <!--     meaning as text     --><type> 
      <text value="Mild TBI"/> 
    </type> 
  </referenceRange> <!--     put the references to the QuestionnairAnswer example here using the derived-From type
        --><derivedFrom> 
    <reference value="QuestionnaireResponse/gcs"/> 
    <display value="GCS form results"/> 
  </derivedFrom> 
</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.