This page is part of the FHIR Specification (v5.0.0-ballot: FHIR R5 Ballot Preview). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2
Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw XML (canonical form + also see XML Format Specification)
Clinical assessment tool example - GCS with individual scores as related QuestionnaireAnswer (id = "gcs-qa")
<?xml version="1.0" encoding="UTF-8"?> <Observation xmlns="http://hl7.org/fhir"> <id value="gcs-qa"/> <!-- the mandatory quality flags: --><text> <status value="generated"/> <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=" Observations are often coded in multiple code systems. - LOINC - or SNOMED -and/or the source system may provides its own "local" code, which may be less or more granular than LOINC. In this example there is only LOINC ">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 agreed human representation, and once in a coded form. In this example the UCUM unit is provided but no human representation since this is often not displayed ">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> </text> <status value="final"/> <!-- Observations are often coded in multiple code systems. - LOINC - or SNOMED -and/or the source system may provides its own "local" code, which may be less or more granular than LOINC. In this example there is only LOINC --><code> <!-- LOINC - always recommended to have a LOINC code --><coding> <system value="http://loinc.org"/> <code value="9269-2"/> <display value="Glasgow coma score total"/> </coding> <text value="Glasgow Coma Scale , (GCS)"/> </code> <subject> <reference value="Patient/example"/> <display value="Peter James Chalmers"/> </subject> <effectiveDateTime value="2014-12-11T04:44:16Z"/> <!-- In FHIR, units may be represented twice. Once in the agreed human representation, and once in a coded form. In this example the UCUM unit is provided but no human representation since this is often not displayed --><valueQuantity> <value value="13"/> <system value="http://unitsofmeasure.org"/> <code value="{score}"/> </valueQuantity> <referenceRange> <high> <value value="8"/> <system value="http://unitsofmeasure.org"/> <code value="{score}"/> </high> <!-- meaning as text --><type> <text value="Severe TBI"/> </type> </referenceRange> <referenceRange> <low> <value value="9"/> <system value="http://unitsofmeasure.org"/> <code value="{score}"/> </low> <high> <value value="12"/> <system value="http://unitsofmeasure.org"/> <code value="{score}"/> </high> <!-- meaning as text --><type> <text value="Moderate TBI"/> </type> </referenceRange> <referenceRange> <low> <value value="13"/> <system value="http://unitsofmeasure.org"/> <code value="{score}"/> </low> <!-- meaning as text --><type> <text value="Mild TBI"/> </type> </referenceRange> <!-- put the references to the QuestionnairAnswer example here using the derived-From type --><derivedFrom> <reference value="QuestionnaireResponse/gcs"/> <display value="GCS form results"/> </derivedFrom> </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.