2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Observation-example-glasgow.xml

Raw XML (canonical form)

Clinical assessment tool example - Glasgow Score (id = "glasgow")

Raw XML

<Observation xmlns="http://hl7.org/fhir">
  <id value="glasgow"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div>
  </text>
  <contained>
    <Observation><!--    Note: will use contained elements for this example but could just as easily use external
       or bundled elements..   --><!--    First contained element = Motor component.    -->
      <id value="motor"/>
      <code>
        <coding>
          <system value="http://loinc.org"/>
          <code value="9268-4"/>
          <display value="Glasgow coma score motor"/>
        </coding>
        <text value="Motor"/>
      </code>
      <valueQuantity>
        <value value="5"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="{score}"/>
      </valueQuantity>
      <appliesDateTime value="2014-12-11T04:44:16Z"/>
      <status value="final"/>
      <reliability value="ok"/>
      <subject>
        <reference value="Patient/example"/>
      </subject>
    </Observation>
  </contained>
  <contained>
    <Observation><!--    Second contained element = Verbal component.    -->
      <id value="verbal"/>
      <code>
        <coding>
          <system value="http://loinc.org"/>
          <code value="9270-0"/>
          <display value="Glasgow coma score verbal"/>
        </coding>
        <text value="Verbal"/>
      </code>
      <valueQuantity>
        <value value="4"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="{score}"/>
      </valueQuantity>
      <appliesDateTime value="2014-12-11T04:44:16Z"/>
      <status value="final"/>
      <reliability value="ok"/>
      <subject>
        <reference value="Patient/example"/>
      </subject>
    </Observation>
  </contained>
  <contained>
    <Observation><!--    Third contained element = Eyes component.    -->
      <id value="eyes"/>
      <code>
        <coding>
          <system value="http://loinc.org"/>
          <code value="9267-6"/>
          <display value="Glasgow coma score eye opening"/>
        </coding>
        <text value="Eyes"/>
      </code>
      <valueQuantity>
        <value value="4"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="{score}"/>
      </valueQuantity>
      <appliesDateTime value="2014-12-11T04:44:16Z"/>
      <status value="final"/>
      <reliability value="ok"/>
      <subject>
        <reference value="Patient/example"/>
      </subject>
    </Observation>
  </contained><!--   
    Observations are often coded in multiple code systems.
      - LOINC
    - or SNOMED
      -and/or the source system may provides it's own &quot;local&quot; 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><!--    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>
  <appliesDateTime value="2014-12-11T04:44:16Z"/><!--    the mandatory quality flags:    -->
  <status value="final"/>
  <reliability value="ok"/>
  <subject>
    <reference value="Patient/example"/>
    <display value="Peter James Chalmers"/>
  </subject>
  <referenceRange>
    <high>
      <value value="8"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="{score}"/>
    </high><!--    meaning as text    -->
    <meaning>
      <text value="Severe TBI"/>
    </meaning>
  </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    -->
    <meaning>
      <text value="Moderate TBI"/>
    </meaning>
  </referenceRange>
  <referenceRange>
    <low>
      <value value="13"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="{score}"/>
    </low><!--    meaning as text    -->
    <meaning>
      <text value="Mild TBI"/>
    </meaning>
  </referenceRange><!--    put the references to the contained components here     -->
  <related>
    <type value="derived-from"/>
    <target>
      <reference value="#motor"/>
      <display value="Motor score"/>
    </target>
  </related>
  <related>
    <type value="derived-from"/>
    <target>
      <reference value="#verbal"/>
      <display value="Verbal score"/>
    </target>
  </related>
  <related>
    <type value="derived-from"/>
    <target>
      <reference value="#eyes"/>
      <display value="Eyes score"/>
    </target>
  </related>
</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.