This page is part of the FHIR Specification (v1.0.0: DSTU 2 Ballot 3). 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
Clinical assessment tool example - GCS using related QuestionnaireAnswer (id = "gcs-qa")
<Observation xmlns="http://hl7.org/fhir"> <id value="gcs-qa"/> <!-- the mandatory quality flags: --> <text><status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: gcs-qa</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 3:44:16 PM</p><p><b>value</b>: 13 {score}<span> (Details: http://unitsofmeasure.org code {score} = '??')</span></p><blockquote><p><b>referenceRange</b></p><p><b>high</b>: 8 {score}<span> (Details: http://unitsofmeasure.org code {score} = '??')</span></p><p><b>meaning</b>: Severe TBI <span>(Details )</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 9 {score}<span> (Details: http://unitsofmeasure.org code {score} = '??')</span></p><p><b>high</b>: 12 {score}<span> (Details: http://unitsofmeasure.org code {score} = '??')</span></p><p><b>meaning</b>: Moderate TBI <span>(Details )</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 13 {score}<span> (Details: http://unitsofmeasure.org code {score} = '??')</span></p><p><b>meaning</b>: Mild TBI <span>(Details )</span></p></blockquote><h3>Relateds</h3><table><tr><td>-</td><td><b>Type</b></td><td><b>Target</b></td></tr><tr><td>*</td><td>derived-from</td><td><a>GCS form results</a></td></tr></table></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 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 --> <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 QuestionnairAnswer example here using the derived-From type --> <related> <type value="derived-from"/> <target> <reference value="QuestionnaireResponse/gcs"/> <display value="GCS form results"/> </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.