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| Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw JSON (canonical form + also see JSON Format Specification)
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/><p><b>code</b>: <span>Glasgow Coma Scale , (GCS)</span></p><p><b>subject</b>: <a>Peter James Chalmers. Generated Summary: Medical record number: 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); , Phone: (03) 5555 6473, Phone: (03) 3410 5613, Phone: (03) 5555 8834; gender: male; birthDate: 1974-12-25; </a></p><p><b>effective</b>: 11 Dec. 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.