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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 score as components
{ "resourceType": "Observation", "id": "glasgow", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>id</b>: glasgow</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><blockquote><p><b>component</b></p><p><b>code</b>: <span>GCS Motor</span></p><p><b>value</b>: <span>5 (Localizes painful stimuli)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span>GSC Verbal</span></p><p><b>value</b>: <span>4 (Confused, disoriented)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span>Eyes</span></p><p><b>value</b>: <span>4 (Opens eyes spontaneously)</span></p></blockquote></div>" }, "status": "final", "code": { "coding": [ { "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": { "value": 13, "system": "http://unitsofmeasure.org", "code": "{score}" }, "referenceRange": [ { "high": { "value": 8, "system": "http://unitsofmeasure.org", "code": "{score}" }, "type": { "text": "Severe TBI" } }, { "low": { "value": 9, "system": "http://unitsofmeasure.org", "code": "{score}" }, "high": { "value": 12, "system": "http://unitsofmeasure.org", "code": "{score}" }, "type": { "text": "Moderate TBI" } }, { "low": { "value": 13, "system": "http://unitsofmeasure.org", "code": "{score}" }, "type": { "text": "Mild TBI" } } ], "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "9268-4", "display": "Glasgow coma score motor" } ], "text": "GCS Motor" }, "valueCodeableConcept": { "coding": [ { "system": "http://acme.ec/codes", "code": "5", "display": "Localizes painful stimuli" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue", "valueDecimal": 5 } ], "system": "http://loinc.org", "code": "LA6566-9", "display": "Localizing pain" } ], "text": "5 (Localizes painful stimuli)" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "9270-0", "display": "Glasgow coma score verbal" } ], "text": "GSC Verbal" }, "valueCodeableConcept": { "coding": [ { "system": "http://acme.ec/codes", "code": "4", "display": "Confused, disoriented" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue", "valueDecimal": 4 } ], "system": "http://loinc.org", "code": "LA6560-2", "display": "Confused" } ], "text": "4 (Confused, disoriented)" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "9267-6", "display": "Glasgow coma score eye opening" } ], "text": "Eyes" }, "valueCodeableConcept": { "coding": [ { "system": "http://acme.ec/codes", "code": "4", "display": "Opens eyes spontaneously" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue", "valueDecimal": 4 } ], "system": "http://loinc.org", "code": "LA6556-0", "display": "Eyes open spontaneously" } ], "text": "4 (Opens eyes spontaneously)" } } ] }
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.