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Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw XML (canonical form + also see XML Format Specification)
Clinical assessment tool example - GCS with individual score as components (id = "glasgow")
<?xml version="1.0" encoding="UTF-8"?> <!-- This is an example of a Glasgow Coma Score using components to group the measurements source http://www.choa.org/~/media/CHOA/Documents/Services/Concussion/Concussion-glasgow-com a-scale.pdf --><Observation xmlns="http://hl7.org/fhir"> <id value="glasgow"/> <!-- the mandatory quality flags: --> <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. The LOINC definitions already have "built" into their definitions, and the codes can be combined with ordinalValue extensions to achieve a score. --> <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> <!-- Using components since these measurements are typically reported and interpreted together --> <!-- GCS motor Component --> <component> <code> <coding> <system value="http://loinc.org"/> <code value="9268-4"/> <display value="Glasgow coma score motor"/> </coding> <text value="GCS Motor"/> </code> <valueCodeableConcept> <coding> <system value="http://example.org/codes"/> <code value="5"/> <display value="Localizes painful stimuli"/> </coding> <coding> <!-- This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource --> <!-- 0..1 Value of extension --> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <!-- from Element: extension --> <valueDecimal value="5"/> </extension> <system value="http://loinc.org"/> <code value="LA6566-9"/> <display value="Localizing pain"/> </coding> <text value="5 (Localizes painful stimuli)"/> </valueCodeableConcept> </component> <!-- GCS verbal Component --> <component> <code> <coding> <system value="http://loinc.org"/> <code value="9270-0"/> <display value="Glasgow coma score verbal"/> </coding> <text value="GSC Verbal"/> </code> <valueCodeableConcept> <coding> <system value="http://example.org/codes"/> <code value="4"/> <display value="Confused, disoriented"/> </coding> <coding> <!-- This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource --> <!-- 0..1 Value of extension --> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <!-- from Element: extension --> <valueDecimal value="4"/> </extension> <system value="http://loinc.org"/> <!-- technicallly the code is '5' and the LA is the identifier to do hav e both would require an extention --> <code value="LA6560-2"/> <display value="Confused"/> </coding> <text value="4 (Confused, disoriented)"/> </valueCodeableConcept> </component> <!-- GCS eyes Component --> <component> <code> <coding> <system value="http://loinc.org"/> <code value="9267-6"/> <display value="Glasgow coma score eye opening"/> </coding> <text value="Eyes"/> </code> <valueCodeableConcept> <coding> <system value="http://example.org/codes"/> <code value="4"/> <display value="Opens eyes spontaneously"/> </coding> <coding> <!-- This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource --> <!-- 0..1 Value of extension --> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <!-- from Element: extension --> <valueDecimal value="4"/> </extension> <system value="http://loinc.org"/> <!-- technicallly the code is '4' and the LA is the identifier to do hav e both would require an extention --> <code value="LA6556-0"/> <display value="Eyes open spontaneously"/> </coding> <text value="4 (Opens eyes spontaneously)"/> </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.
FHIR ®© HL7.org 2011+. FHIR R6 hl7.fhir.core#6.0.0-ballot2 generated on Fri, Dec 6, 2024 22:32+0000.
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