Release 5 Preview #2

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Observation-example-2minute-apgar-score.xml

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

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Example of a 2 minute Apgar score with individual score as components (id = "2minute-apgar-score")

<?xml version="1.0" encoding="UTF-8"?>

<Observation xmlns="http://hl7.org/fhir">
  <id value="2minute-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> : 2minute-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> : 2 minute Apgar Score <span> (Details : {LOINC code '9273-4' = '2 minute Apgar Score', given as '2 minute Apgar Score'})</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> : 5 {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> : 1. Good color in body with bluish hands or feet <span> (Details : {LOINC code 'LA6723-6' = 'Good color in body with bluish hands or feet', given
             as 'Good color in body with bluish hands or feet'}; {http://acme.ped/apgarcolor code '1'
             = '1)</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> : 1. Fewer than 100 beats per minute <span> (Details : {LOINC code 'LA6720-2' = 'Grimace during suctioning', given as 'Fewer than
             100 beats per minute'}; {http://acme.ped/apgarheartrate code '1' = '1)</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> : 1. Grimace during suctioning <span> (Details : {LOINC code 'LA6721-0' = 'Grimace and pulling away, cough, or sneeze during
             suctioning', given as 'Grimace during suctioning'}; {http://acme.ped/apgarreflexirritability
             code '1' = '1)</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> : 1. Some flexion of arms and legs <span> (Details : {LOINC code 'LA6714-5' = 'Some flexion of arms and legs', given as 'Some flexion
             of arms and legs'}; {http://acme.ped/apgarmuscletone code '1' = '1)</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> : 1. Weak cry; may sound like whimpering, slow or irregular breathing <span> (Details : {LOINC code 'LA6726-9' = 'Weak cry; may sound like whimpering, slow or irregular
             breathing', given as 'Weak cry; may sound like whimpering, slow or irregular breathing'};
             {http://acme.ped/apgarrespiratoryeffort code '1' = '1)</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://loinc.org"/> 
      <code value="9273-4"/> 
      <display value="2 minute Apgar Score"/> 
    </coding> 
    <text value="2 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="5"/> 
    <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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6723-6"/> 
        <display value="Good color in body with bluish hands or feet"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarcolor"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Good color in body with bluish hands or feet"/> 
    </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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6720-2"/> 
        <display value="Fewer than 100 beats per minute"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarheartrate"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Fewer than 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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6721-0"/> 
        <display value="Grimace during suctioning"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarreflexirritability"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Grimace 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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6714-5"/> 
        <display value="Some flexion of arms and legs"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarmuscletone"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Some flexion of arms and legs"/> 
    </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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6726-9"/> 
        <display value="Weak cry; may sound like whimpering, slow or irregular breathing"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarrespiratoryeffort"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Weak cry; may sound like whimpering, slow or irregular 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.