Release 5 Ballot
DiagnosticsThis 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 
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| Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
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Clinical assessment tool example - GCS with individual score as components
@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <http://loinc.org/rdf#> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
[a fhir:Observation;
fhir:nodeRole fhir:treeRoot;
fhir:Resource.id [ fhir:value "glasgow"];
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Observation</b><a name=\"glasgow\"> </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 "glasgow" </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 - or SNOMED\n -and/or the source system may provides its own "local" code, which may be less or more granular than LOINC.\n In 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><blockquote><p><b>component</b></p><p><b>code</b>: GCS Motor <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9268-4 "Glasgow coma score motor")</span></p><p><b>value</b>: 5 (Localizes painful stimuli) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#5 "Localizes painful stimuli"; <a href=\"https://loinc.org/\">LOINC</a>#LA6566-9 "Localizing pain")</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: GSC Verbal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9270-0 "Glasgow coma score verbal")</span></p><p><b>value</b>: 4 (Confused, disoriented) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#4 "Confused, disoriented"; <a href=\"https://loinc.org/\">LOINC</a>#LA6560-2 "Confused")</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Eyes <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9267-6 "Glasgow coma score eye opening")</span></p><p><b>value</b>: 4 (Opens eyes spontaneously) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#4 "Opens eyes spontaneously"; <a href=\"https://loinc.org/\">LOINC</a>#LA6556-0 "Eyes open spontaneously")</span></p></blockquote></div>"
];
fhir:Observation.status [ fhir:value "final"];
fhir:Observation.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:9269-2;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "9269-2" ];
fhir:Coding.display [ fhir:value "Glasgow coma score total" ]
];
fhir:CodeableConcept.text [ fhir:value "Glasgow Coma Scale , (GCS)" ]
];
fhir:Observation.subject [
fhir:Reference.reference [ fhir:value "Patient/example" ];
fhir:Reference.display [ fhir:value "Peter James Chalmers" ]
];
fhir:Observation.effectiveDateTime [ fhir:value "2014-12-11T04:44:16Z"^^xsd:dateTime];
fhir:Observation.valueQuantity [
fhir:Quantity.value [ fhir:value "13"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "{score}" ]
];
fhir:Observation.referenceRange [
fhir:index 0;
fhir:Observation.referenceRange.high [
fhir:Quantity.value [ fhir:value "8"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "{score}" ]
];
fhir:Observation.referenceRange.type [
fhir:CodeableConcept.text [ fhir:value "Severe TBI" ]
]
], [
fhir:index 1;
fhir:Observation.referenceRange.low [
fhir:Quantity.value [ fhir:value "9"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "{score}" ]
];
fhir:Observation.referenceRange.high [
fhir:Quantity.value [ fhir:value "12"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "{score}" ]
];
fhir:Observation.referenceRange.type [
fhir:CodeableConcept.text [ fhir:value "Moderate TBI" ]
]
], [
fhir:index 2;
fhir:Observation.referenceRange.low [
fhir:Quantity.value [ fhir:value "13"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "{score}" ]
];
fhir:Observation.referenceRange.type [
fhir:CodeableConcept.text [ fhir:value "Mild TBI" ]
]
];
fhir:Observation.component [
fhir:index 0;
fhir:Observation.component.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:9268-4;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "9268-4" ];
fhir:Coding.display [ fhir:value "Glasgow coma score motor" ]
];
fhir:CodeableConcept.text [ fhir:value "GCS Motor" ]
];
fhir:Observation.component.valueCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://acme.ec/codes" ];
fhir:Coding.code [ fhir:value "5" ];
fhir:Coding.display [ fhir:value "Localizes painful stimuli" ]
], [
fhir:index 1;
a loinc:LA6566-9;
fhir:Element.extension [
fhir:index 0;
fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/itemWeight" ];
fhir:Extension.valueDecimal [ fhir:value "5"^^xsd:decimal ]
];
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "LA6566-9" ];
fhir:Coding.display [ fhir:value "Localizing pain" ]
];
fhir:CodeableConcept.text [ fhir:value "5 (Localizes painful stimuli)" ]
]
], [
fhir:index 1;
fhir:Observation.component.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:9270-0;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "9270-0" ];
fhir:Coding.display [ fhir:value "Glasgow coma score verbal" ]
];
fhir:CodeableConcept.text [ fhir:value "GSC Verbal" ]
];
fhir:Observation.component.valueCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://acme.ec/codes" ];
fhir:Coding.code [ fhir:value "4" ];
fhir:Coding.display [ fhir:value "Confused, disoriented" ]
], [
fhir:index 1;
a loinc:LA6560-2;
fhir:Element.extension [
fhir:index 0;
fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/itemWeight" ];
fhir:Extension.valueDecimal [ fhir:value "4"^^xsd:decimal ]
];
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "LA6560-2" ];
fhir:Coding.display [ fhir:value "Confused" ]
];
fhir:CodeableConcept.text [ fhir:value "4 (Confused, disoriented)" ]
]
], [
fhir:index 2;
fhir:Observation.component.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:9267-6;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "9267-6" ];
fhir:Coding.display [ fhir:value "Glasgow coma score eye opening" ]
];
fhir:CodeableConcept.text [ fhir:value "Eyes" ]
];
fhir:Observation.component.valueCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http://acme.ec/codes" ];
fhir:Coding.code [ fhir:value "4" ];
fhir:Coding.display [ fhir:value "Opens eyes spontaneously" ]
], [
fhir:index 1;
a loinc:LA6556-0;
fhir:Element.extension [
fhir:index 0;
fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/itemWeight" ];
fhir:Extension.valueDecimal [ fhir:value "4"^^xsd:decimal ]
];
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "LA6556-0" ];
fhir:Coding.display [ fhir:value "Eyes open spontaneously" ]
];
fhir:CodeableConcept.text [ fhir:value "4 (Opens eyes spontaneously)" ]
]
]] .
# - ontology header ------------------------------------------------------------
[a owl:Ontology;
owl:imports fhir:fhir.ttl] .
# -------------------------------------------------------------------------------------
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.
FHIR ®© HL7.org 2011+. FHIR R5 Ballot hl7.fhir.core#5.0.0-ballot generated on Wed, Sep 7, 2022 11:10+1000.
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