FHIR Release 3 (STU) CI-Build

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Observation-example-glasgow.xml

Example Observation/glasgow (XML)

Maturity Level : N/A
Responsible Owner: Orders and Observations Work Group Ballot Standards Status : Informative Compartments : Device , Encounter , Group , Patient , Practitioner , RelatedPerson

Raw XML ( canonical form ) Jump past Narrative + also see XML Format Specification )

Clinical assessment tool example - GCS using related Observations with individual score as components (id = "glasgow")

(Details : {LOINC code '9269-2' = 'Glasgow coma score total', given as 'Glasgow coma score total'})(Details : {LOINC code '9268-4' = 'Glasgow coma score motor', given as 'Glasgow coma score motor'})(Details : {http:/acme.ec/gcsmotor code '5' = '5', given as 'Localizes painful stimuli'}; {LOINC code 'LA6566-9' = 'Localizing pain', given as 'Localizing pain'})(Details : {LOINC code '9270-0' = 'Glasgow coma score verbal', given as 'Glasgow coma score verbal'})(Details : {http:/acme.ec/gcsverbal code '4' = '4', given as 'Confused, disoriented'}; {LOINC code 'LA6560-2' = 'Confused', given as 'Confused'})(Details : {LOINC code '9267-6' = 'Glasgow coma score eye opening', given as 'Glasgow coma score eye opening'})(Details : {http:/acme.ec/gcseye code '4' = '4', given as 'Opens eyes spontaneously'}; {LOINC code 'LA6556-0' = 'Eyes open spontaneously', given as 'Eyes open spontaneously'}) <!-- FHIR build is generating the narratives <text> <status value="generated"></status> <div xmlns="http://www.w3.org/1999/xhtml"> <h2>Observation: Glasgow Coma Scale , (GCS)</h2> <h3>Date Time: 2014-12-11 20:44PM</h3> <h3>Patient Name: Peter James Chalmers</h3> <ul> <li> <b>Glasgow Coma Scale , (GCS)=</b>13<ul> <li> <b>Motor=</b>5</li> <li> <b>Verbal=</b>4</li> <li> <b>Eyes=</b>4</li> </ul></li> </ul>
<?xml version="1.0" encoding="UTF-8"?>


     </div>
  </text>
    -->
  <!--     Note: will use contained elements for this example but could just as easily use external
     or bundled elements..    -->
  
    
      
      
      
        
          
          
          
        
        
      
      
        
      
      
      
        
          
          
          
        
        
        <!--      This example has the extension which maps a numeric score to the code this may already
           be known and unecessary in the Observation resource     -->
          
          
            
          
          
          
          
          
        
        
      
    
  
  
  
    
      
      
      
        
          
          
          
        
        
      
      
        
      
      
      
        
          
          
          
        
        
        <!--      This example has the extension which maps a numeric score to the code this may already
           be known and unecessary in the Observation resource     -->
          
          
            
          
          
          
        <!--    technicallly the code is '5' and the LA is the identifier to do hav e both  would require
           an extention    -->
          
          
        
        
      
    
  
  
  
    
      
      
      
        
          
          
          
        
        
      
      
        
      
      
      
        
          
          
          
        
        
        <!--      This example has the extension which maps a numeric score to the code this may already
           be known and unecessary in the Observation resource     -->
          
          
            
          
          
          
        <!--    technicallly the code is '4' and the LA is the identifier to do hav e both  would require
           an extention    -->
          
          
        
        
      
    
  

  
<!--    
    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
      -->
  
  
    
      
      
      
    
    
  
  
    
    
  
  
<!--     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
       -->
  
    
    
    
  
  
    
      
      
      
    
  
    
      
    
  
  
    
      
      
      
    
    
      
      
      
    
  
    
      
    
  
  
    
      
      
      
    
  
    
      
    
  
<!--     put the references to the contained components here using the derived-From type  
      -->
  
    
    
      
      
    
  
  
    
    
      
      
    
  
  
    
    
      
      
    
  

<!--   
 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

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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.