This page is part of the FHIR Specification (v4.5.0: R5 Preview #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
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)
Clinical assessment tool example - GCS with individual scores as related QuestionnaireAnswer (id = "gcs-qa")
<?xml version="1.0" encoding="UTF-8"?> <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</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> </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 --><type> <text value="Severe TBI"/> </type> </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 --><type> <text value="Moderate TBI"/> </type> </referenceRange> <referenceRange> <low> <value value="13"/> <system value="http://unitsofmeasure.org"/> <code value="{score}"/> </low> <!-- meaning as text --><type> <text value="Mild TBI"/> </type> </referenceRange> <!-- put the references to the QuestionnairAnswer example here using the derived-From type --><derivedFrom> <reference value="QuestionnaireResponse/gcs"/> <display value="GCS form results"/> </derivedFrom> </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.