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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: <http://loinc.org/rdf#> .@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 -------------------------------------------------------------------<http://hl7.org/fhir/Observation/glasgow> a fhir:Observation; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "glasgow"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: glasgow</p><p><b>status</b>: final</p><p><b>code</b>: Glasgow Coma Scale , (GCS) <span>(Details : {LOINC code '9269-2' = 'Glasgow coma score total', given as 'Glasgow coma score total'})</span></p><p><b>subject</b>: <a>Peter James Chalmers</a></p><p><b>effective</b>: 11/12/2014 4:44:16 AM</p><p><b>value</b>: 13 {score}<span> (Details: UCUM code {score} = '{score}')</span></p><blockquote><p><b>referenceRange</b></p><p><b>high</b>: 8 {score}<span> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Severe TBI <span>(Details )</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 9 {score}<span> (Details: UCUM code {score} = '{score}')</span></p><p><b>high</b>: 12 {score}<span> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Moderate TBI <span>(Details )</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 13 {score}<span> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Mild TBI <span>(Details )</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: GCS Motor <span>(Details : {LOINC code '9268-4' = 'Glasgow coma score motor', given as 'Glasgow coma score motor'})</span></p><p><b>value</b>: 5 (Localizes painful stimuli) <span>(Details : {http://acme.ec/codes code '5' = '5', given as 'Localizes painful stimuli'}; {LOINC code 'LA6566-9' = 'Localizing pain', given as 'Localizing pain'})</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: GSC Verbal <span>(Details : {LOINC code '9270-0' = 'Glasgow coma score verbal', given as 'Glasgow coma score verbal'})</span></p><p><b>value</b>: 4 (Confused, disoriented) <span>(Details : {http://acme.ec/codes code '4' = '4', given as 'Confused, disoriented'}; {LOINC code 'LA6560-2' = 'Confused', given as 'Confused'})</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Eyes <span>(Details : {LOINC code '9267-6' = 'Glasgow coma score eye opening', given as 'Glasgow coma score eye opening'})</span></p><p><b>value</b>: 4 (Opens eyes spontaneously) <span>(Details : {http://acme.ec/codes code '4' = '4', given as 'Opens eyes spontaneously'}; {LOINC code 'LA6556-0' = 'Eyes open spontaneously', given as 'Eyes open spontaneously'})</span></p></blockquote></div>" ]; fhir:Observation.status [ fhir:value "final"]; fhir:Observation.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:9269-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "9269-2" ]; fhir:Coding.display [ fhir:value "Glasgow coma score total" ] ]; fhir:CodeableConcept.text [ fhir:value "Glasgow Coma Scale , (GCS)" ] ]; fhir:Observation.subject [ fhir:link <http://hl7.org/fhir/Patient/example>; fhir:Reference.reference [ fhir:value "Patient/example" ]; fhir:Reference.display [ fhir:value "Peter James Chalmers" ] ]; fhir:Observation.effectiveDateTime [ fhir:value "2014-12-11T04:44:16Z"^^xsd:dateTime]; fhir:Observation.valueQuantity [ fhir:Quantity.value [ fhir:value "13"^^xsd:decimal ]; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ]; fhir:Quantity.code [ fhir:value "{score}" ] ]; fhir:Observation.referenceRange [ fhir:index 0; fhir:Observation.referenceRange.high [ fhir:Quantity.value [ fhir:value "8"^^xsd:decimal ]; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ]; fhir:Quantity.code [ fhir:value "{score}" ] ]; fhir:Observation.referenceRange.type [ fhir:CodeableConcept.text [ fhir:value "Severe TBI" ] ] ], [ fhir:index 1; fhir:Observation.referenceRange.low [ fhir:Quantity.value [ fhir:value "9"^^xsd:decimal ]; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ]; fhir:Quantity.code [ fhir:value "{score}" ] ]; fhir:Observation.referenceRange.high [ fhir:Quantity.value [ fhir:value "12"^^xsd:decimal ]; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ]; fhir:Quantity.code [ fhir:value "{score}" ] ]; fhir:Observation.referenceRange.type [ fhir:CodeableConcept.text [ fhir:value "Moderate TBI" ] ] ], [ fhir:index 2; fhir:Observation.referenceRange.low [ fhir:Quantity.value [ fhir:value "13"^^xsd:decimal ]; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ]; fhir:Quantity.code [ fhir:value "{score}" ] ]; fhir:Observation.referenceRange.type [ fhir:CodeableConcept.text [ fhir:value "Mild TBI" ] ] ]; fhir:Observation.component [ fhir:index 0; fhir:Observation.component.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:9268-4; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "9268-4" ]; fhir:Coding.display [ fhir:value "Glasgow coma score motor" ] ]; fhir:CodeableConcept.text [ fhir:value "GCS Motor" ] ]; fhir:Observation.component.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://acme.ec/codes" ]; fhir:Coding.code [ fhir:value "5" ]; fhir:Coding.display [ fhir:value "Localizes painful stimuli" ] ], [ fhir:index 1; a loinc:LA6566-9; fhir:Element.extension [ fhir:index 0; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/ordinalValue" ]; fhir:Extension.valueDecimal [ fhir:value "5"^^xsd:decimal ] ]; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "LA6566-9" ]; fhir:Coding.display [ fhir:value "Localizing pain" ] ]; fhir:CodeableConcept.text [ fhir:value "5 (Localizes painful stimuli)" ][a fhir:Observation ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "glasgow"] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir: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 - or SNOMED\n -and/or the source system may provides its own "local" code, which may be less or more granular than LOINC.\n In 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>" ] ; # the mandatory quality flags: fhir:status [ fhir:v "final"] ; # 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 # 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://acme.ec/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:index 1; fhir:Observation.component.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:9270-0; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "9270-0" ]; fhir:Coding.display [ fhir:value "Glasgow coma score verbal" ] ]; fhir:CodeableConcept.text [ fhir:value "GSC Verbal" ] ]; fhir:Observation.component.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://acme.ec/codes" ]; fhir:Coding.code [ fhir:value "4" ]; fhir:Coding.display [ fhir:value "Confused, disoriented" ] ], [ fhir:index 1; a loinc:LA6560-2; fhir:Element.extension [ fhir:index 0; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/ordinalValue" ]; fhir:Extension.valueDecimal [ fhir:value "4"^^xsd:decimal ] ]; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "LA6560-2" ]; fhir:Coding.display [ fhir:value "Confused" ] ]; fhir:CodeableConcept.text [ fhir:value "4 (Confused, disoriented)" ]] [ 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://acme.ec/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:index 2; fhir:Observation.component.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:9267-6; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "9267-6" ]; fhir:Coding.display [ fhir:value "Glasgow coma score eye opening" ] ]; fhir:CodeableConcept.text [ fhir:value "Eyes" ] ]; fhir:Observation.component.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; fhir:Coding.system [ fhir:value "http://acme.ec/codes" ]; fhir:Coding.code [ fhir:value "4" ]; fhir:Coding.display [ fhir:value "Opens eyes spontaneously" ] ], [ fhir:index 1; a loinc:LA6556-0; fhir:Element.extension [ fhir:index 0; fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/ordinalValue" ]; fhir:Extension.valueDecimal [ fhir:value "4"^^xsd:decimal ] ]; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "LA6556-0" ]; fhir:Coding.display [ fhir:value "Eyes open spontaneously" ] ]; fhir:CodeableConcept.text [ fhir:value "4 (Opens eyes spontaneously)" ]] [ 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://acme.ec/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)" ] ]] . <http://hl7.org/fhir/Patient/example> a fhir:Patient . # - ontology header ------------------------------------------------------------ <http://hl7.org/fhir/Observation/glasgow.ttl> a owl:Ontology; owl:imports fhir:fhir.ttl; owl:versionIRI <http://build.fhir.org/Observation/glasgow.ttl> .] )] . # 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.
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