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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 scores as related QuestionnaireAnswer
{ "resourceType": "Observation", "id": "gcs-qa", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Observation</b><a name=\"gcs-qa\"> </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 "gcs-qa" </p></div><p><b>status</b>: <span title=\" the mandatory quality flags: \">final</span></p><p><b>code</b>: <span title=\" \n Observations are often coded in multiple code systems.\n - LOINC\n\t\t- or SNOMED\n -and/or the source system may provides its own "local" code, which may be less or more granular than LOINC.\n\tIn this example there is only LOINC\n \">Glasgow Coma Scale , (GCS) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9269-2 "Glasgow coma score total")</span></span></p><p><b>subject</b>: <a href=\"patient-example.html\">Patient/example: Peter James Chalmers</a> "Peter CHALMERS"</p><p><b>effective</b>: 2014-12-11T04:44:16Z</p><p><b>value</b>: <span title=\" In FHIR, units may be represented twice. Once in the\n agreed human representation, and once in a coded form.\n In this example the UCUM unit is provided but no human representation since this is often not displayed\n \">13 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></span></p><blockquote><p><b>referenceRange</b></p><p><b>high</b>: 8 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: <span title=\" meaning as text \">Severe TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 9 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>high</b>: 12 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: <span title=\" meaning as text \">Moderate TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 13 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: <span title=\" meaning as text \">Mild TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></span></p></blockquote><p><b>derivedFrom</b>: <span title=\" put the references to the QuestionnairAnswer example here using the derived-From type \"><a href=\"questionnaireresponse-example-gcs.html\">QuestionnaireResponse/gcs: GCS form results</a></span></p></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" } } ], "derivedFrom": [ { "reference": "QuestionnaireResponse/gcs", "display": "GCS form results" } ] }
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.