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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)
Example of a 1 minute Apgar score with individual score as components
{ "resourceType": "Observation", "id": "1minute-apgar-score", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Observation</b><a name=\"1minute-apgar-score\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Observation "1minute-apgar-score" </p></div><p><b>status</b>: final</p><p><b>category</b>: Survey <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/3.1.0/CodeSystem-observation-category.html\">Observation Category Codes</a>#survey)</span></p><p><b>code</b>: 1 minute Apgar Score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9272-6; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#169895004 "Apgar at 1 minute")</span></p><p><b>subject</b>: <a name=\"newborn\"> </a></p><blockquote><p><b>Peter James Chalmers </b> male, DoB: 2016-05-18 ( id: 12345)</p></blockquote><p><b>effective</b>: 2016-05-18T22:33:22Z</p><p><b>performer</b>: <a href=\"practitioner-example.html\">Practitioner/example</a> "Adam CAREFUL"</p><p><b>value</b>: 0 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><blockquote><p><b>component</b></p><p><b>code</b>: Apgar color score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#32406-1 "1 minute Apgar Color"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249227004)</span></p><p><b>value</b>: 0. The baby's whole body is completely bluish-gray or pale <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6722-8 "The baby's whole body is completely bluish-gray or pale"; apgarcolor#0)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar respiratory effort score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#32407-9 "1 minute Apgar Heart Rate"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249223000 "Apgar heart rate score")</span></p><p><b>value</b>: 0. No heart rate <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6716-0 "No heart rate"; apgarheartrate#0)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar response to stimulus score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#32409-5 "1 minute Apgar Reflex Irritability"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249226008)</span></p><p><b>value</b>: 0. No response to airways being suctioned <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6719-4 "No response to airways being suctioned"; apgarreflexirritability#0)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar muscle tone score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#32408-7 "1 minute Apgar Muscle Tone"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249225007)</span></p><p><b>value</b>: 0. Limp; no movement <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6713-7 "Limp; no movement"; apgarmuscletone#0)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar respiratory effort score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#32410-3 "1 minute Apgar Respiratory effort"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249224006)</span></p><p><b>value</b>: 0. Not breathing <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6725-1 "Not breathing"; apgarrespiratoryeffort#0)</span></p></blockquote></div>" }, "contained": [ { "resourceType": "Patient", "id": "newborn", "identifier": [ { "system": "http://acmehealthcare/org/mrns", "value": "12345" } ], "active": true, "name": [ { "family": "Chalmers", "given": [ "Peter", "James" ] } ], "gender": "male", "birthDate": "2016-05-18", "_birthDate": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/patient-birthTime", "valueDateTime": "2016-05-18T10:28:45Z" } ] } } ], "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "Survey" } ], "text": "Survey" } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9272-6", "display": "1 minute Apgar Score" }, { "system": "http://snomed.info/sct", "code": "169895004", "display": "Apgar at 1 minute" } ], "text": "1 minute Apgar Score" }, "subject": { "reference": "#newborn" }, "effectiveDateTime": "2016-05-18T22:33:22Z", "performer": [ { "reference": "Practitioner/example" } ], "valueQuantity": { "value": 0, "system": "http://unitsofmeasure.org", "code": "{score}" }, "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "32406-1", "display": "1 minute Apgar Color" }, { "system": "http://snomed.info/sct", "code": "249227004", "display": "Apgar color score" } ], "text": "Apgar color score" }, "valueCodeableConcept": { "coding": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/itemWeight", "valueDecimal": 0 } ], "system": "http://loinc.org", "code": "LA6722-8", "display": "The baby's whole body is completely bluish-gray or pale" }, { "system": "http://acme.ped/apgarcolor", "code": "0" } ], "text": "0. The baby's whole body is completely bluish-gray or pale" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32407-9", "display": "1 minute Apgar Heart Rate" }, { "system": "http://snomed.info/sct", "code": "249223000", "display": "Apgar heart rate score" } ], "text": "Apgar respiratory effort score" }, "valueCodeableConcept": { "coding": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/itemWeight", "valueDecimal": 0 } ], "system": "http://loinc.org", "code": "LA6716-0", "display": "No heart rate" }, { "system": "http://acme.ped/apgarheartrate", "code": "0" } ], "text": "0. No heart rate" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32409-5", "display": "1 minute Apgar Reflex Irritability" }, { "system": "http://snomed.info/sct", "code": "249226008", "display": "Apgar response to stimulus score" } ], "text": "Apgar response to stimulus score" }, "valueCodeableConcept": { "coding": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/itemWeight", "valueDecimal": 0 } ], "system": "http://loinc.org", "code": "LA6719-4", "display": "No response to airways being suctioned" }, { "system": "http://acme.ped/apgarreflexirritability", "code": "0" } ], "text": "0. No response to airways being suctioned" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32408-7", "display": "1 minute Apgar Muscle Tone" }, { "system": "http://snomed.info/sct", "code": "249225007", "display": "Apgar muscle tone score" } ], "text": "Apgar muscle tone score" }, "valueCodeableConcept": { "coding": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/itemWeight", "valueDecimal": 0 } ], "system": "http://loinc.org", "code": "LA6713-7", "display": "Limp; no movement" }, { "system": "http://acme.ped/apgarmuscletone", "code": "0" } ], "text": "0. Limp; no movement" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32410-3", "display": "1 minute Apgar Respiratory effort" }, { "system": "http://snomed.info/sct", "code": "249224006", "display": "Apgar respiratory effort score" } ], "text": "Apgar respiratory effort score" }, "valueCodeableConcept": { "coding": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/itemWeight", "valueDecimal": 0 } ], "system": "http://loinc.org", "code": "LA6725-1", "display": "Not breathing" }, { "system": "http://acme.ped/apgarrespiratoryeffort", "code": "0" } ], "text": "0. Not breathing" } } ] }
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.