DSTU2 QA Preview
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Clinical assessment tool example - GCS using related Observations
{
"resourceType": "Observation",
"id": "glasgow",
"text": {
"status": "generated",
"div": "<div><p><b>Generated Narrative with Details</b></p><p><b>id</b>: glasgow</p><p><b>contained</b>: , , </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><blockquote><p><b>related</b></p><p><b>type</b>: derived-from</p><p><b>target</b>: Motor score. Generated Summary: id: motor; status: final; GCS motor <span>(Details : {LOINC code '9268-4' = 'Glasgow coma score motor', given as 'Glasgow coma score motor'})</span>; Patient/example; effective: 11/12/2014 3:44:16 PM; 5 (Localizes painful stimuli) <span>(Details : {http:/acme.ec/gcsmotor code '5' = '??', given as 'Localizes painful stimuli'}; {LOINC code 'LA6566-9' = 'Localizing pain', given as 'Localizing pain'})</span></p></blockquote><blockquote><p><b>related</b></p><p><b>type</b>: derived-from</p><p><b>target</b>: Verbal score. Generated Summary: id: verbal; status: final; Verbal <span>(Details : {LOINC code '9270-0' = 'Glasgow coma score verbal', given as 'Glasgow coma score verbal'})</span>; Patient/example; effective: 11/12/2014 3:44:16 PM; 4 (Confused, disoriented) <span>(Details : {http:/acme.ec/gcsverbal code '4' = '??', given as 'Confused, disoriented'}; {LOINC code 'LA6560-2' = 'Confused', given as 'Confused'})</span></p></blockquote><blockquote><p><b>related</b></p><p><b>type</b>: derived-from</p><p><b>target</b>: Eyes score. Generated Summary: id: eyes; status: final; Eyes <span>(Details : {LOINC code '9267-6' = 'Glasgow coma score eye opening', given as 'Glasgow coma score eye opening'})</span>; Patient/example; effective: 11/12/2014 3:44:16 PM; 4 (Opens eyes spontaneously) <span>(Details : {http:/acme.ec/gcseye code '4' = '??', given as 'Opens eyes spontaneously'}; {LOINC code 'LA6556-0' = 'Eyes open spontaneously', given as 'Eyes open spontaneously'})</span></p></blockquote></div>"
},
"contained": [
{
"resourceType": "Observation",
"id": "motor",
"status": "final",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "9268-4",
"display": "Glasgow coma score motor"
}
],
"text": "GCS motor"
},
"subject": {
"reference": "Patient/example"
},
"effectiveDateTime": "2014-12-11T04:44:16Z",
"valueCodeableConcept": {
"coding": [
{
"system": "http:/acme.ec/gcsmotor",
"code": "5",
"display": "Localizes painful stimuli"
},
{
"extension": [
{
"fhir_comments": [
" 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 "
],
"url": "http://hl7.org/fhir/StructureDefinition/iso21090-CO-value",
"valueDecimal": 5,
"_valueDecimal": {
"fhir_comments": [
" from Element: extension "
]
}
}
],
"system": "http://loinc.org",
"code": "LA6566-9",
"display": "Localizing pain"
}
],
"text": "5 (Localizes painful stimuli)"
}
},
{
"resourceType": "Observation",
"id": "verbal",
"status": "final",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "9270-0",
"display": "Glasgow coma score verbal"
}
],
"text": "Verbal"
},
"subject": {
"reference": "Patient/example"
},
"effectiveDateTime": "2014-12-11T04:44:16Z",
"valueCodeableConcept": {
"coding": [
{
"system": "http:/acme.ec/gcsverbal",
"code": "4",
"display": "Confused, disoriented"
},
{
"extension": [
{
"fhir_comments": [
" 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 "
],
"url": "http://hl7.org/fhir/StructureDefinition/iso21090-CO-value",
"valueDecimal": 4,
"_valueDecimal": {
"fhir_comments": [
" from Element: extension "
]
}
}
],
"system": "http://loinc.org",
"code": "LA6560-2",
"_code": {
"fhir_comments": [
" technicallly the code is '5' and the LA is the identifier to do hav e both would require an extention "
]
},
"display": "Confused"
}
],
"text": "4 (Confused, disoriented)"
}
},
{
"resourceType": "Observation",
"id": "eyes",
"status": "final",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "9267-6",
"display": "Glasgow coma score eye opening"
}
],
"text": "Eyes"
},
"subject": {
"reference": "Patient/example"
},
"effectiveDateTime": "2014-12-11T04:44:16Z",
"valueCodeableConcept": {
"coding": [
{
"system": "http:/acme.ec/gcseye",
"code": "4",
"display": "Opens eyes spontaneously"
},
{
"extension": [
{
"fhir_comments": [
" 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 "
],
"url": "http://hl7.org/fhir/StructureDefinition/iso21090-CO-value",
"valueDecimal": 4,
"_valueDecimal": {
"fhir_comments": [
" from Element: extension "
]
}
}
],
"system": "http://loinc.org",
"code": "LA6556-0",
"_code": {
"fhir_comments": [
" technicallly the code is '4' and the LA is the identifier to do hav e both would require an extention "
]
},
"display": "Eyes open spontaneously"
}
],
"text": "4 (Opens eyes spontaneously)"
}
}
],
"status": "final",
"_status": {
"fhir_comments": [
" the mandatory quality flags: "
]
},
"code": {
"fhir_comments": [
" \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 "
],
"coding": [
{
"fhir_comments": [
" LOINC - always recommended to have a LOINC code "
],
"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"
},
"effectiveDateTime": "2014-12-11T04:44:16Z",
"valueQuantity": {
"fhir_comments": [
" 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 "
],
"value": 13,
"system": "http://unitsofmeasure.org",
"code": "{score}"
},
"referenceRange": [
{
"high": {
"value": 8,
"system": "http://unitsofmeasure.org",
"code": "{score}"
},
"meaning": {
"fhir_comments": [
" meaning as text "
],
"text": "Severe TBI"
}
},
{
"low": {
"value": 9,
"system": "http://unitsofmeasure.org",
"code": "{score}"
},
"high": {
"value": 12,
"system": "http://unitsofmeasure.org",
"code": "{score}"
},
"meaning": {
"fhir_comments": [
" meaning as text "
],
"text": "Moderate TBI"
}
},
{
"low": {
"value": 13,
"system": "http://unitsofmeasure.org",
"code": "{score}"
},
"meaning": {
"fhir_comments": [
" meaning as text "
],
"text": "Mild TBI"
}
}
],
"related": [
{
"fhir_comments": [
" put the references to the contained components here using the derived-From type "
],
"type": "derived-from",
"target": {
"reference": "#motor",
"display": "Motor score"
}
},
{
"type": "derived-from",
"target": {
"reference": "#verbal",
"display": "Verbal score"
}
},
{
"type": "derived-from",
"target": {
"reference": "#eyes",
"display": "Eyes score"
}
}
]
}
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.
© HL7.org 2011+. FHIR DSTU2 (v1.0.0-6850) generated on Tue, Sep 1, 2015 14:42+1000.
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