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| Orders and Observations Work Group | Maturity Level : N/A | Standards Status : Informative | Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson |
Raw JSON ( canonical form + also see JSON Format Specification )
Clinical assessment tool example - GCS with individual score as components
{
"resourceType": "Observation",
"id": "glasgow",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></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 "glasgow" </p></div><p><b>status</b>: final</p><p><b>code</b>: Glasgow Coma Scale , (GCS) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9269-2 "Glasgow coma score total")</span></p><p><b>subject</b>: <a href=\"patient-example.html\">Patient/example: Peter James Chalmers</a> "Peter CHALMERS"</p><p><b>effective</b>: 2014-12-11T04:44:16Z</p><p><b>value</b>: 13 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><blockquote><p><b>referenceRange</b></p><p><b>high</b>: 8 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Severe TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 9 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>high</b>: 12 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Moderate TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 13 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Mild TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: GCS Motor <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9268-4 "Glasgow coma score motor")</span></p><p><b>value</b>: 5 (Localizes painful stimuli) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#5 "Localizes painful stimuli"; <a href=\"https://loinc.org/\">LOINC</a>#LA6566-9 "Localizing pain")</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: GSC Verbal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9270-0 "Glasgow coma score verbal")</span></p><p><b>value</b>: 4 (Confused, disoriented) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#4 "Confused, disoriented"; <a href=\"https://loinc.org/\">LOINC</a>#LA6560-2 "Confused")</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Eyes <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9267-6 "Glasgow coma score eye opening")</span></p><p><b>value</b>: 4 (Opens eyes spontaneously) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#4 "Opens eyes spontaneously"; <a href=\"https://loinc.org/\">LOINC</a>#LA6556-0 "Eyes open spontaneously")</span></p></blockquote></div>"
"resourceType" : "Observation",
"id" : "glasgow",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Observation</b><a name=\"glasgow\"> </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 "glasgow" </p></div><p><b>status</b>: <span title=\" the mandatory quality flags: \">final</span></p><p><b>code</b>: <span title=\" \n Observations are often coded in multiple code systems.\n - LOINC\n\t\t- or SNOMED\n -and/or the source system may provides its own "local" code, which may be less or more granular than LOINC.\n\tIn this example there is only LOINC\n \">Glasgow Coma Scale , (GCS) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9269-2 "Glasgow coma score total")</span></span></p><p><b>subject</b>: <a href=\"patient-example.html\">Patient/example: Peter James Chalmers</a> "Peter CHALMERS"</p><p><b>effective</b>: 2014-12-11T04:44:16Z</p><p><b>value</b>: <span title=\" In FHIR, units may be represented twice. Once in the\n agreed human representation, and once in a coded form.\n In this example the UCUM unit is provided but no human representation since this is often not displayed\n \">13 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></span></p><blockquote><p><b>referenceRange</b></p><p><b>high</b>: 8 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: <span title=\" meaning as text \">Severe TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 9 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>high</b>: 12 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: <span title=\" meaning as text \">Moderate TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 13 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: <span title=\" meaning as text \">Mild TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: GCS Motor <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9268-4 "Glasgow coma score motor")</span></p><p><b>value</b>: 5 (Localizes painful stimuli) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#5 "Localizes painful stimuli"; <a href=\"https://loinc.org/\">LOINC</a>#LA6566-9 "Localizing pain")</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: GSC Verbal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9270-0 "Glasgow coma score verbal")</span></p><p><b>value</b>: 4 (Confused, disoriented) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#4 "Confused, disoriented"; <a href=\"https://loinc.org/\">LOINC</a>#LA6560-2 "Confused")</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Eyes <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9267-6 "Glasgow coma score eye opening")</span></p><p><b>value</b>: 4 (Opens eyes spontaneously) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#4 "Opens eyes spontaneously"; <a href=\"https://loinc.org/\">LOINC</a>#LA6556-0 "Eyes open spontaneously")</span></p></blockquote></div>"
},
"status": "final",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "9269-2",
"display": "Glasgow coma score total"
}
],
"text": "Glasgow Coma Scale , (GCS)"
"status" : "final",
"code" : {
"coding" : [{
"system" : "http://loinc.org",
"code" : "9269-2",
"display" : "Glasgow coma score total"
}],
"text" : "Glasgow Coma Scale , (GCS)"
},
"subject": {
"reference": "Patient/example",
"display": "Peter James Chalmers"
"subject" : {
"reference" : "Patient/example",
"display" : "Peter James Chalmers"
},
"effectiveDateTime": "2014-12-11T04:44:16Z",
"valueQuantity": {
"value": 13,
"system": "http://unitsofmeasure.org",
"code": "{score}"
"effectiveDateTime" : "2014-12-11T04:44:16Z",
"valueQuantity" : {
"value" : 13,
"system" : "http://unitsofmeasure.org",
"code" : "{score}"
},
"referenceRange": [
{
"high": {
"value": 8,
"system": "http://unitsofmeasure.org",
"code": "{score}"
},
"type": {
"text": "Severe TBI"
}
"referenceRange" : [{
"high" : {
"value" : 8,
"system" : "http://unitsofmeasure.org",
"code" : "{score}"
},
{
"low": {
"value": 9,
"system": "http://unitsofmeasure.org",
"code": "{score}"
},
"high": {
"value": 12,
"system": "http://unitsofmeasure.org",
"code": "{score}"
},
"type": {
"text": "Moderate TBI"
}
"type" : {
"text" : "Severe TBI"
}
},
{
"low" : {
"value" : 9,
"system" : "http://unitsofmeasure.org",
"code" : "{score}"
},
{
"low": {
"value": 13,
"system": "http://unitsofmeasure.org",
"code": "{score}"
},
"type": {
"text": "Mild TBI"
}
"high" : {
"value" : 12,
"system" : "http://unitsofmeasure.org",
"code" : "{score}"
},
"type" : {
"text" : "Moderate TBI"
}
],
"component": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "9268-4",
"display": "Glasgow coma score motor"
}
],
"text": "GCS Motor"
},
{
"low" : {
"value" : 13,
"system" : "http://unitsofmeasure.org",
"code" : "{score}"
},
"type" : {
"text" : "Mild TBI"
}
}],
"component" : [{
"code" : {
"coding" : [{
"system" : "http://loinc.org",
"code" : "9268-4",
"display" : "Glasgow coma score motor"
}],
"text" : "GCS Motor"
},
"valueCodeableConcept" : {
"coding" : [{
"system" : "http://acme.ec/codes",
"code" : "5",
"display" : "Localizes painful stimuli"
},
"valueCodeableConcept": {
"coding": [
{
"system": "http://acme.ec/codes",
"code": "5",
"display": "Localizes painful stimuli"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/ordinalValue",
"valueDecimal": 5
}
],
"system": "http://loinc.org",
"code": "LA6566-9",
"display": "Localizing pain"
}
],
"text": "5 (Localizes painful stimuli)"
}
{
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/itemWeight",
"valueDecimal" : 5
}],
"system" : "http://loinc.org",
"code" : "LA6566-9",
"display" : "Localizing pain"
}],
"text" : "5 (Localizes painful stimuli)"
}
},
{
"code" : {
"coding" : [{
"system" : "http://loinc.org",
"code" : "9270-0",
"display" : "Glasgow coma score verbal"
}],
"text" : "GSC Verbal"
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "9270-0",
"display": "Glasgow coma score verbal"
}
],
"text": "GSC Verbal"
"valueCodeableConcept" : {
"coding" : [{
"system" : "http://acme.ec/codes",
"code" : "4",
"display" : "Confused, disoriented"
},
"valueCodeableConcept": {
"coding": [
{
"system": "http://acme.ec/codes",
"code": "4",
"display": "Confused, disoriented"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/ordinalValue",
"valueDecimal": 4
}
],
"system": "http://loinc.org",
"code": "LA6560-2",
"display": "Confused"
}
],
"text": "4 (Confused, disoriented)"
}
{
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/itemWeight",
"valueDecimal" : 4
}],
"system" : "http://loinc.org",
"code" : "LA6560-2",
"display" : "Confused"
}],
"text" : "4 (Confused, disoriented)"
}
},
{
"code" : {
"coding" : [{
"system" : "http://loinc.org",
"code" : "9267-6",
"display" : "Glasgow coma score eye opening"
}],
"text" : "Eyes"
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "9267-6",
"display": "Glasgow coma score eye opening"
}
],
"text": "Eyes"
"valueCodeableConcept" : {
"coding" : [{
"system" : "http://acme.ec/codes",
"code" : "4",
"display" : "Opens eyes spontaneously"
},
"valueCodeableConcept": {
"coding": [
{
"system": "http://acme.ec/codes",
"code": "4",
"display": "Opens eyes spontaneously"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/ordinalValue",
"valueDecimal": 4
}
],
"system": "http://loinc.org",
"code": "LA6556-0",
"display": "Eyes open spontaneously"
}
],
"text": "4 (Opens eyes spontaneously)"
}
{
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/itemWeight",
"valueDecimal" : 4
}],
"system" : "http://loinc.org",
"code" : "LA6556-0",
"display" : "Eyes open spontaneously"
}],
"text" : "4 (Opens eyes spontaneously)"
}
]
}]
}
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
Release
4B
(v4.3.0)
hl7.fhir.r4b.core#4.3.0
R5
hl7.fhir.core#5.0.0-draft-final
generated
on
Sat,
May
28,
2022
12:56+1000.
Wed,
Mar
1,
2023
23:07+1100.
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