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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"?> <Observation xmlns="http://hl7.org/fhir"> <id value="glasgow"/>display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60% <!--<!-- the mandatory quality flags: --> <text> <status value="generated"/> <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=" 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.-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 ">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 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 ">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> </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<!-- 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 displayedIn 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 --><!-- 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://acme.ec/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 --><!-- This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource --> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <!-- from Element: extension --> <valueDecimal value="5"/><!-- 0..1 Value of extension --> </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://acme.ec/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 --><!-- This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource --> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <!-- from Element: extension --> <valueDecimal value="4"/><!-- 0..1 Value of extension --> </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 --><!-- 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://acme.ec/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 --><!-- This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource --> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <!-- from Element: extension --> <valueDecimal value="4"/><!-- 0..1 Value of extension --> </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 --><!-- 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.
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hl7.fhir.r4b.core#4.3.0
R5
hl7.fhir.core#5.0.0-draft-final
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Sat,
May
28,
2022
12:56+1000.
Wed,
Mar
1,
2023
23:07+1100.
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