Observation-example-2minute-apgar-score.xml

Example of a 2 minute Apgar score with individual score as components (id = "2minute-apgar-score")

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

<Observation xmlns="http://hl7.org/fhir">
  <id value="2minute-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> <div> <p> Resource &quot;2minute-apgar-score&quot; </p> </div> <p> <b> status</b> : final</p> <p> <b> category</b> : Survey <span>  (<a> Observation Category Codes</a> #survey)</span> </p> <p> <b> code</b> : 2 minute Apgar Score <span>  (<a> LOINC</a> #9273-4)</span> </p> <p> <b> subject</b> : <a>  </a> </p> <blockquote> <div> <p> Resource &quot;newborn&quot; </p> </div> <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> : 2016-05-18T22:33:22Z</p> <p> <b> performer</b> : <a> Practitioner/example</a>  &quot;Adam CAREFUL&quot;</p> <p> <b> value</b> : 5 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar color score <span>  (<a> SNOMED CT</a> #249227004)</span> </p> <p> <b> value</b> : 1. Good color in body with bluish hands or feet <span>  (<a> LOINC</a> #LA6723-6 &quot;Good color in body with bluish hands or feet&quot;; apgarcolor#1)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span>  (<a> SNOMED CT</a> #249223000 &quot;Apgar heart rate score&quot;)</span> </p> <p> <b> value</b> : 1. Fewer than 100 beats per minute <span>  (<a> LOINC</a> #LA6720-2 &quot;Fewer than 100 beats per minute&quot;; apgarheartrate#1)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar response to stimulus score <span>  (<a> SNOMED CT</a> #249226008)</span> </p> <p> <b> value</b> : 1. Grimace during suctioning <span>  (<a> LOINC</a> #LA6721-0 &quot;Grimace during suctioning&quot;; apgarreflexirritability#1)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar muscle tone score <span>  (<a> SNOMED CT</a> #249225007)</span> </p> <p> <b> value</b> : 1. Some flexion of arms and legs <span>  (<a> LOINC</a> #LA6714-5 &quot;Some flexion of arms and legs&quot;; apgarmuscletone#1)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span>  (<a> SNOMED CT</a> #249224006)</span> </p> <p> <b> value</b> : 1. Weak cry; may sound like whimpering, slow or irregular breathing <span>  (<a> LOINC</a> #LA6726-9 &quot;Weak cry; may sound like whimpering, slow or irregular breathing&quot;;
             apgarrespiratoryeffort#1)</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="9273-4"/> 
      <display value="2 minute Apgar Score"/> 
    </coding> 
    <text value="2 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="5"/> 
    <system value="http://unitsofmeasure.org"/> 
    <code value="{score}"/> 
  </valueQuantity> 
  <component> 
    <code> 
      <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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6723-6"/> 
        <display value="Good color in body with bluish hands or feet"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarcolor"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Good color in body with bluish hands or feet"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6720-2"/> 
        <display value="Fewer than 100 beats per minute"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarheartrate"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Fewer than 100 beats per minute"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6721-0"/> 
        <display value="Grimace during suctioning"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarreflexirritability"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Grimace during suctioning"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6714-5"/> 
        <display value="Some flexion of arms and legs"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarmuscletone"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Some flexion of arms and legs"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6726-9"/> 
        <display value="Weak cry; may sound like whimpering, slow or irregular breathing"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarrespiratoryeffort"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Weak cry; may sound like whimpering, slow or irregular breathing"/> 
    </valueCodeableConcept> 
  </component> 
</Observation>