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Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
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Clinical assessment tool example - GCS with individual score as components
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <https://loinc.org/rdf/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- # # 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-coma-scale.pdf # [a fhir:Observation ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "glasgow"] ; # fhir:status [ fhir:v "final"] ; # the mandatory quality flags: fhir:code [ fhir:coding ( [ a loinc:9269-2 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "9269-2" ] ; fhir:display [ fhir:v "Glasgow coma score total" ] ] ) ; # LOINC - always recommended to have a LOINC code fhir:text [ fhir:v "Glasgow Coma Scale , (GCS)" ] ] ; # # 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. # fhir:subject [ fhir:reference [ fhir:v "Patient/example" ] ; fhir:display [ fhir:v "Peter James Chalmers" ] ] ; # fhir:effective [ fhir:v "2014-12-11T04:44:16Z"^^xsd:dateTime] ; # fhir:value [ a fhir:Quantity ; fhir:value [ fhir:v "13"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "{score}" ] ] ; # 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 # fhir:referenceRange ( [ fhir:high [ fhir:value [ fhir:v "8"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "{score}" ] ] ; fhir:type [ fhir:text [ fhir:v "Severe TBI" ] ] # meaning as text ] [ fhir:low [ fhir:value [ fhir:v "9"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "{score}" ] ] ; fhir:high [ fhir:value [ fhir:v "12"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "{score}" ] ] ; fhir:type [ fhir:text [ fhir:v "Moderate TBI" ] ] # meaning as text ] [ fhir:low [ fhir:value [ fhir:v "13"^^xsd:decimal ] ; fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "{score}" ] ] ; fhir:type [ fhir:text [ fhir:v "Mild TBI" ] ] # meaning as text ] ) ; # fhir:component ( [ fhir:code [ fhir:coding ( [ a loinc:9268-4 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "9268-4" ] ; fhir:display [ fhir:v "Glasgow coma score motor" ] ] ) ; fhir:text [ fhir:v "GCS Motor" ] ] ; fhir:value [ a fhir:CodeableConcept ; fhir:coding ( [ fhir:system [ fhir:v "http://example.org/codes"^^xsd:anyURI ] ; fhir:code [ fhir:v "5" ] ; fhir:display [ fhir:v "Localizes painful stimuli" ] ] [ a loinc:LA6566-9 ; fhir:extension ( [ fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/itemWeight"^^xsd:anyURI ] ; fhir:value [ fhir:v "5"^^xsd:decimal ] # from Element: extension ] ) ; # 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 fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "LA6566-9" ] ; fhir:display [ fhir:v "Localizing pain" ] ] ) ; fhir:text [ fhir:v "5 (Localizes painful stimuli)" ] ] ] [ fhir:code [ fhir:coding ( [ a loinc:9270-0 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "9270-0" ] ; fhir:display [ fhir:v "Glasgow coma score verbal" ] ] ) ; fhir:text [ fhir:v "GSC Verbal" ] ] ; fhir:value [ a fhir:CodeableConcept ; fhir:coding ( [ fhir:system [ fhir:v "http://example.org/codes"^^xsd:anyURI ] ; fhir:code [ fhir:v "4" ] ; fhir:display [ fhir:v "Confused, disoriented" ] ] [ a loinc:LA6560-2 ; fhir:extension ( [ fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/itemWeight"^^xsd:anyURI ] ; fhir:value [ fhir:v "4"^^xsd:decimal ] # from Element: extension ] ) ; # 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 fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "LA6560-2" ] ; # technicallly the code is '5' and the LA is the identifier to do hav e both would require an extention fhir:display [ fhir:v "Confused" ] ] ) ; fhir:text [ fhir:v "4 (Confused, disoriented)" ] ] ] [ fhir:code [ fhir:coding ( [ a loinc:9267-6 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "9267-6" ] ; fhir:display [ fhir:v "Glasgow coma score eye opening" ] ] ) ; fhir:text [ fhir:v "Eyes" ] ] ; fhir:value [ a fhir:CodeableConcept ; fhir:coding ( [ fhir:system [ fhir:v "http://example.org/codes"^^xsd:anyURI ] ; fhir:code [ fhir:v "4" ] ; fhir:display [ fhir:v "Opens eyes spontaneously" ] ] [ a loinc:LA6556-0 ; fhir:extension ( [ fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/itemWeight"^^xsd:anyURI ] ; fhir:value [ fhir:v "4"^^xsd:decimal ] # from Element: extension ] ) ; # 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 fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "LA6556-0" ] ; # technicallly the code is '4' and the LA is the identifier to do hav e both would require an extention fhir:display [ fhir:v "Eyes open spontaneously" ] ] ) ; fhir:text [ fhir:v "4 (Opens eyes spontaneously)" ] ] ] )] . # Using components since these measurements are typically reported and interpreted together , GCS motor Component # -------------------------------------------------------------------------------------
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 Wed, Nov 6, 2024 22:17+0000.
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