Release 5 Draft Ballot

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Observation-example-5minute-apgar-score.xml

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

Raw XML (canonical form + also see XML Format Specification)

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Example of a 5 minute Apgar score with individual score as components (id = "5minute-apgar-score")

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

<Observation xmlns="http://hl7.org/fhir">
  <id value="5minute-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</b> </p> <p/>  <p> <b> category</b> : <span> Survey</span> </p> <p> <b> code</b> : <span> 5 minute Apgar Score</span> </p> <p> <b> subject</b> : <a>  </a> </p> <blockquote> <p> <b> identifier</b> : id: 12345</p> <p> <b> active</b> : true</p> <p> <b> name</b> : Peter James Chalmers </p> <p> <b> gender</b> : male</p> <p> <b> birthDate</b> : 2016-05-18</p> </blockquote> <p> <b> effective</b> : 19 May 2016, 8:33:22 am</p> <p> <b> performer</b> : <a> Generated Summary: id: 23; active; Adam Careful </a> </p> <p> <b> value</b> : 10 {score}</p> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : <span> Apgar color score</span> </p> <p> <b> value</b> : <span> 2. Good color all over</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : <span> Apgar respiratory effort score</span> </p> <p> <b> value</b> : <span> 2. At least 100 beats per minute</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : <span> Apgar response to stimulus score</span> </p> <p> <b> value</b> : <span> 2. Grimace and pulling away, cough, or sneeze during suctioning</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : <span> Apgar muscle tone score</span> </p> <p> <b> value</b> : <span> 2. Active motion</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : <span> Apgar respiratory effort score</span> </p> <p> <b> value</b> : <span> 2. Good, strong cry; normal rate and effort of breathing</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="9274-2"/> 
      <display value="5 minute Apgar Score"/> 
    </coding> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="169909004"/> 
      <display value="Apgar at 5 minutes"/> 
    </coding> 
    <text value="5 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://loinc.org"/> 
        <code value="32411-1"/> 
        <display value="5 minute Apgar Color"/> 
      </coding> 
      <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://loinc.org"/> 
        <code value="32412-9"/> 
        <display value="5 minute Apgar Heart Rate"/> 
      </coding> 
      <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://loinc.org"/> 
        <code value="32414-5"/> 
        <display value="5 minute Apgar Reflex Irritability"/> 
      </coding> 
      <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://loinc.org"/> 
        <code value="32413-7"/> 
        <display value="5 minute Apgar Muscle Tone"/> 
      </coding> 
      <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://loinc.org"/> 
        <code value="32415-2"/> 
        <display value="5 minute Apgar Respiratory effort"/> 
      </coding> 
      <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.