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Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
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Clinical assessment tool example - GCS with individual scores as related QuestionnaireAnswer
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <http://loinc.org/rdf#> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- <http://hl7.org/fhir/Observation/gcs-qa> a fhir:Observation; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "gcs-qa"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>id</b>: gcs-qa</p><p/><p><b>code</b>: <span>Glasgow Coma Scale , (GCS)</span></p><p><b>subject</b>: <a>Peter James Chalmers. Generated Summary: id: example; Medical record number: 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); -unknown-(HOME), ph: (03) 5555 6473(WORK), ph: (03) 3410 5613(MOBILE), ph: (03) 5555 8834(OLD); gender: male; birthDate: 1974-12-25; </a></p><p><b>effective</b>: 11/12/2014 3:44:16 PM</p><p><b>value</b>: 13 {score}</p><blockquote><p><b>referenceRange</b></p><p><b>high</b>: 8 {score}</p><p><b>type</b>: <span>Severe TBI</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 9 {score}</p><p><b>high</b>: 12 {score}</p><p><b>type</b>: <span>Moderate TBI</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 13 {score}</p><p><b>type</b>: <span>Mild TBI</span></p></blockquote><p><b>derivedFrom</b>: <a>GCS form results. Generated Summary: id: gcs; questionnaire: http://hl7.org/fhir/Questionnaire/gcs; status: completed; authored: 11/12/2014 3:44:16 PM</a></p></div>" ]; fhir:Observation.status [ fhir:value "final"]; fhir:Observation.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:9269-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "9269-2" ]; fhir:Coding.display [ fhir:value "Glasgow coma score total" ] ]; fhir:CodeableConcept.text [ fhir:value "Glasgow Coma Scale , (GCS)" ] ]; fhir:Observation.subject [ fhir:link <http://hl7.org/fhir/Patient/example>; fhir:Reference.reference [ fhir:value "Patient/example" ]; fhir:Reference.display [ fhir:value "Peter James Chalmers" ] ]; fhir:Observation.effectiveDateTime [ fhir:value "2014-12-11T04:44:16Z"^^xsd:dateTime]; fhir:Observation.valueQuantity [ fhir:Quantity.value [ fhir:value "13"^^xsd:decimal ]; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ]; fhir:Quantity.code [ fhir:value "{score}" ] ]; fhir:Observation.referenceRange [ fhir:index 0; fhir:Observation.referenceRange.high [ fhir:Quantity.value [ fhir:value "8"^^xsd:decimal ]; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ]; fhir:Quantity.code [ fhir:value "{score}" ] ]; fhir:Observation.referenceRange.type [ fhir:CodeableConcept.text [ fhir:value "Severe TBI" ] ] ], [ fhir:index 1; fhir:Observation.referenceRange.low [ fhir:Quantity.value [ fhir:value "9"^^xsd:decimal ]; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ]; fhir:Quantity.code [ fhir:value "{score}" ] ]; fhir:Observation.referenceRange.high [ fhir:Quantity.value [ fhir:value "12"^^xsd:decimal ]; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ]; fhir:Quantity.code [ fhir:value "{score}" ] ]; fhir:Observation.referenceRange.type [ fhir:CodeableConcept.text [ fhir:value "Moderate TBI" ] ] ], [ fhir:index 2; fhir:Observation.referenceRange.low [ fhir:Quantity.value [ fhir:value "13"^^xsd:decimal ]; fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ]; fhir:Quantity.code [ fhir:value "{score}" ] ]; fhir:Observation.referenceRange.type [ fhir:CodeableConcept.text [ fhir:value "Mild TBI" ] ] ]; fhir:Observation.derivedFrom [ fhir:index 0; fhir:link <http://hl7.org/fhir/QuestionnaireResponse/gcs>; fhir:Reference.reference [ fhir:value "QuestionnaireResponse/gcs" ]; fhir:Reference.display [ fhir:value "GCS form results" ] ] . <http://hl7.org/fhir/Patient/example> a fhir:Patient . <http://hl7.org/fhir/QuestionnaireResponse/gcs> a fhir:QuestionnaireResponse . # - ontology header ------------------------------------------------------------ <http://hl7.org/fhir/Observation/gcs-qa.ttl> a owl:Ontology; owl:imports fhir:fhir.ttl; owl:versionIRI <http://build.fhir.org/Observation/gcs-qa.ttl> . # -------------------------------------------------------------------------------------
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.