This page is part of the FHIR Specification (v4.4.0: R5 Preview #2). 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
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)
Example of a 20 minute Apgar score with individual score as components (id = "20minute-apgar-score")
<?xml version="1.0" encoding="UTF-8"?> <Observation xmlns="http://hl7.org/fhir"> <id value="20minute-apgar-score"/> <!-- Using a contained patient for the purposes of this example Observation. Typically the reference would be to an external resource --><text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : 20minute-apgar-score</p> <p> <b> contained</b> : </p> <p> <b> status</b> : final</p> <p> <b> category</b> : Survey <span> (Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'survey' = 'Survey', given as 'Survey'})</span> </p> <p> <b> code</b> : 20 minute Apgar Score <span> (Details : {SNOMED CT code '443849008' = 'Apgar score at 20 minutes', given as 'Apgar score at 20 minutes'})</span> </p> <p> <b> subject</b> : id: newborn; 12345; active; Peter James Chalmers ; gender: male; birthDate: 2016-05-18</p> <p> <b> effective</b> : 19/05/2016 8:33:22 AM</p> <p> <b> performer</b> : <a> Practitioner/example</a> </p> <p> <b> value</b> : 10 {score}<span> (Details: UCUM code {score} = '{score}')</span> </p> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar color score <span> (Details : {SNOMED CT code '249227004' = 'Apgar color score', given as 'Apgar color score'})</span> </p> <p> <b> value</b> : 2. Good color all over <span> (Details : {LOINC code 'LA6724-4' = 'Good color all over', given as 'Good color all over'}; {http://acme.ped/apgarcolor code '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span> (Details : {SNOMED CT code '249223000' = 'Apgar heart rate score', given as 'Apgar heart rate score'})</span> </p> <p> <b> value</b> : 2. At least 100 beats per minute <span> (Details : {LOINC code 'LA6718-6' = 'At least 100 beats per minute', given as 'At least 100 beats per minute'}; {http://acme.ped/apgarheartrate code '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar response to stimulus score <span> (Details : {SNOMED CT code '249226008' = 'Apgar response to stimulus score', given as 'Apgar response to stimulus score'})</span> </p> <p> <b> value</b> : 2. Grimace and pulling away, cough, or sneeze during suctioning <span> (Details : {LOINC code 'LA6721-0' = 'Grimace and pulling away, cough, or sneeze during suctioning', given as 'Grimace and pulling away, cough, or sneeze during suctioning'}; {http://acme.ped/apgarreflexirritability code '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar muscle tone score <span> (Details : {SNOMED CT code '249225007' = 'Apgar muscle tone score', given as 'Apgar muscle tone score'})</span> </p> <p> <b> value</b> : 2. Active motion <span> (Details : {LOINC code 'LA6715-2' = 'Active motion', given as 'Active motion '}; {http://acme.ped/ap garmuscletone code '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span> (Details : {SNOMED CT code '249224006' = 'Apgar respiratory effort score', given as 'Apgar respiratory effort score'})</span> </p> <p> <b> value</b> : 2. Good, strong cry; normal rate and effort of breathing <span> (Details : {LOINC code 'LA6727-7' = 'Good, strong cry; normal rate and effort of breathing', given as 'Good, strong cry; normal rate and effort of breathing '}; {http://acme.ped/apgarrespira toryeffort code '2' = '2)</span> </p> </blockquote> </div> </text> <contained> <Patient> <id value="newborn"/> <!-- MRN assigned by ACME healthcare on --><identifier> <system value="http://acmehealthcare/org/mrns"/> <value value="12345"/> </identifier> <active value="true"/> <!-- Peter James Chalmers --><name> <family value="Chalmers"/> <given value="Peter"/> <given value="James"/> </name> <!-- use FHIR code system for male / female --><gender value="male"/> <birthDate value="2016-05-18"> <extension url="http://hl7.org/fhir/StructureDefinition/patient-birthTime"> <valueDateTime value="2016-05-18T10:28:45Z"/> </extension> </birthDate> </Patient> </contained> <status value="final"/> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/observation-category"/> <code value="survey"/> <display value="Survey"/> </coding> <text value="Survey"/> </category> <code> <coding> <system value="http://snomed.info/sct"/> <code value="443849008"/> <display value="Apgar score at 20 minutes"/> </coding> <text value="20 minute Apgar Score"/> </code> <subject> <reference value="#newborn"/> </subject> <effectiveDateTime value="2016-05-18T22:33:22Z"/> <performer> <reference value="Practitioner/example"/> </performer> <valueQuantity> <value value="10"/> <system value="http://unitsofmeasure.org"/> <code value="{score}"/> </valueQuantity> <component> <code> <coding> <system value="http://snomed.info/sct"/> <code value="249227004"/> <display value="Apgar color score"/> </coding> <text value="Apgar color score"/> </code> <valueCodeableConcept> <coding> <!-- this extension maps a numeric score to the code this may already be known and unecessary --><extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue"> <valueDecimal value="2"/> </extension> <system value="http://loinc.org"/> <code value="LA6724-4"/> <display value="Good color all over"/> </coding> <coding> <system value="http://acme.ped/apgarcolor"/> <code value="2"/> </coding> <text value="2. Good color all over"/> </valueCodeableConcept> </component> <component> <code> <coding> <system value="http://snomed.info/sct"/> <code value="249223000"/> <display value="Apgar heart rate score"/> </coding> <text value="Apgar respiratory effort score"/> </code> <valueCodeableConcept> <coding> <!-- this extension maps a numeric score to the code this may already be known and unecessary --><extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue"> <valueDecimal value="2"/> </extension> <system value="http://loinc.org"/> <code value="LA6718-6"/> <display value="At least 100 beats per minute"/> </coding> <coding> <system value="http://acme.ped/apgarheartrate"/> <code value="2"/> </coding> <text value="2. At least 100 beats per minute"/> </valueCodeableConcept> </component> <component> <code> <coding> <system value="http://snomed.info/sct"/> <code value="249226008"/> <display value="Apgar response to stimulus score"/> </coding> <text value="Apgar response to stimulus score"/> </code> <valueCodeableConcept> <coding> <!-- this extension maps a numeric score to the code this may already be known and unecessary --><extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue"> <valueDecimal value="2"/> </extension> <system value="http://loinc.org"/> <code value="LA6721-0"/> <display value="Grimace and pulling away, cough, or sneeze during suctioning"/> </coding> <coding> <system value="http://acme.ped/apgarreflexirritability"/> <code value="2"/> </coding> <text value="2. Grimace and pulling away, cough, or sneeze during suctioning"/> </valueCodeableConcept> </component> <component> <code> <coding> <system value="http://snomed.info/sct"/> <code value="249225007"/> <display value="Apgar muscle tone score"/> </coding> <text value="Apgar muscle tone score"/> </code> <valueCodeableConcept> <coding> <!-- this extension maps a numeric score to the code this may already be known and unecessary --><extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue"> <valueDecimal value="2"/> </extension> <system value="http://loinc.org"/> <code value="LA6715-2"/> <display value="Active motion "/> </coding> <coding> <system value="http://acme.ped/apgarmuscletone"/> <code value="2"/> </coding> <text value="2. Active motion"/> </valueCodeableConcept> </component> <component> <code> <coding> <system value="http://snomed.info/sct"/> <code value="249224006"/> <display value="Apgar respiratory effort score"/> </coding> <text value="Apgar respiratory effort score"/> </code> <valueCodeableConcept> <coding> <!-- this extension maps a numeric score to the code this may already be known and unecessary --><extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue"> <valueDecimal value="2"/> </extension> <system value="http://loinc.org"/> <code value="LA6727-7"/> <display value="Good, strong cry; normal rate and effort of breathing "/> </coding> <coding> <system value="http://acme.ped/apgarrespiratoryeffort"/> <code value="2"/> </coding> <text value="2. Good, strong cry; normal rate and effort of breathing"/> </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.