R5 Final QA
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. Page versions: R5 R4B R4 R3
| Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
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Example of a 5 minute Apgar score with individual score as components
@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
[a fhir:Observation ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "5minute-apgar-score"] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Observation</b><a name=\"5minute-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 "5minute-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/4.0.0/CodeSystem-observation-category.html\">Observation Category Codes</a>#survey)</span></p><p><b>code</b>: 5 minute Apgar Score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9274-2; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#169909004 "Apgar at 5 minutes")</span></p><p><b>subject</b>: <a name=\"newborn\"> </a></p><blockquote><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\"><b>Peter James Chalmers </b> male, DoB: 2016-05-18 ( id: 12345)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Record is active\">Active:</td><td colspan=\"3\">true</td></tr></table></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>: 10 {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>#32411-1 "5 minute Apgar Color"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249227004)</span></p><p><b>value</b>: 2. Good color all over <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6724-4 "Good color all over"; apgarcolor#2)</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>#32412-9 "5 minute Apgar Heart Rate"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249223000 "Apgar heart rate score")</span></p><p><b>value</b>: 2. At least 100 beats per minute <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6718-6 "At least 100 beats per minute"; apgarheartrate#2)</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>#32414-5 "5 minute Apgar Reflex Irritability"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249226008)</span></p><p><b>value</b>: 2. Grimace and pulling away, cough, or sneeze during suctioning <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6721-0 "Grimace and pulling away, cough, or sneeze during suctioning"; apgarreflexirritability#2)</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>#32413-7 "5 minute Apgar Muscle Tone"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249225007)</span></p><p><b>value</b>: 2. Active motion <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6715-2 "Active motion"; apgarmuscletone#2)</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>#32415-2 "5 minute Apgar Respiratory effort"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249224006)</span></p><p><b>value</b>: 2. Good, strong cry; normal rate and effort of breathing <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6727-7 "Good, strong cry; normal rate and effort of breathing"; apgarrespiratoryeffort#2)</span></p></blockquote></div>"
] ; # Using a contained patient for the purposes of this example Observation. Typically the reference would be to an external resource
fhir:contained ( [
a fhir:Patient ;
fhir:id [ fhir:v "newborn" ] ;
fhir:identifier ( [
fhir:system [ fhir:v "http://acmehealthcare/org/mrns"^^xsd:anyURI ] ;
fhir:value [ fhir:v "12345" ]
] ) ; # MRN assigned by ACME healthcare on
fhir:active [ fhir:v "true"^^xsd:boolean ] ;
fhir:name ( [
fhir:family [ fhir:v "Chalmers" ] ;
fhir:given ( [ fhir:v "Peter" ] [ fhir:v "James" ] )
] ) ; # Peter James Chalmers
fhir:gender [ fhir:v "male" ] ; # use FHIR code system for male \/ female
fhir:birthDate [
fhir:v "2016-05-18"^^xsd:date ;
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/patient-birthTime"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2016-05-18T10:28:45Z"^^xsd:dateTime ]
] )
]
] ) ; #
fhir:status [ fhir:v "final"] ; #
fhir:category ( [
fhir:coding ( [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/observation-category"^^xsd:anyURI ] ;
fhir:code [ fhir:v "survey" ] ;
fhir:display [ fhir:v "Survey" ]
] ) ;
fhir:text [ fhir:v "Survey" ]
] ) ; #
fhir:code [
fhir:coding ( [
a loinc:9274-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "9274-2" ] ;
fhir:display [ fhir:v "5 minute Apgar Score" ]
] [
a sct:169909004 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "169909004" ] ;
fhir:display [ fhir:v "Apgar at 5 minutes" ]
] ) ;
fhir:text [ fhir:v "5 minute Apgar Score" ]
] ; #
fhir:subject [
fhir:reference [ fhir:v "#newborn" ]
] ; #
fhir:effective [ fhir:v "2016-05-18T22:33:22Z"^^xsd:dateTime] ; #
fhir:performer ( [
fhir:reference [ fhir:v "Practitioner/example" ]
] ) ; #
fhir:value [
a fhir:Quantity ;
fhir:value [ fhir:v "10"^^xsd:decimal ] ;
fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "{score}" ]
] ; #
fhir:component ( [
fhir:code [
fhir:coding ( [
a loinc:32411-1 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "32411-1" ] ;
fhir:display [ fhir:v "5 minute Apgar Color" ]
] [
a sct:249227004 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "249227004" ] ;
fhir:display [ fhir:v "Apgar color score" ]
] ) ;
fhir:text [ fhir:v "Apgar color score" ]
] ;
fhir:value [
a fhir:CodeableConcept ;
fhir:coding ( [
a loinc:LA6724-4 ;
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/itemWeight"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2"^^xsd:decimal ]
] ) ; # this extension maps a numeric score to the code this may already be known and unecessary
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "LA6724-4" ] ;
fhir:display [ fhir:v "Good color all over" ]
] [
fhir:system [ fhir:v "http://acme.ped/apgarcolor"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ]
] ) ;
fhir:text [ fhir:v "2. Good color all over" ]
]
] [
fhir:code [
fhir:coding ( [
a loinc:32412-9 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "32412-9" ] ;
fhir:display [ fhir:v "5 minute Apgar Heart Rate" ]
] [
a sct:249223000 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "249223000" ] ;
fhir:display [ fhir:v "Apgar heart rate score" ]
] ) ;
fhir:text [ fhir:v "Apgar respiratory effort score" ]
] ;
fhir:value [
a fhir:CodeableConcept ;
fhir:coding ( [
a loinc:LA6718-6 ;
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/itemWeight"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2"^^xsd:decimal ]
] ) ; # this extension maps a numeric score to the code this may already be known and unecessary
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "LA6718-6" ] ;
fhir:display [ fhir:v "At least 100 beats per minute" ]
] [
fhir:system [ fhir:v "http://acme.ped/apgarheartrate"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ]
] ) ;
fhir:text [ fhir:v "2. At least 100 beats per minute" ]
]
] [
fhir:code [
fhir:coding ( [
a loinc:32414-5 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "32414-5" ] ;
fhir:display [ fhir:v "5 minute Apgar Reflex Irritability" ]
] [
a sct:249226008 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "249226008" ] ;
fhir:display [ fhir:v "Apgar response to stimulus score" ]
] ) ;
fhir:text [ fhir:v "Apgar response to stimulus score" ]
] ;
fhir:value [
a fhir:CodeableConcept ;
fhir:coding ( [
a loinc:LA6721-0 ;
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/itemWeight"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2"^^xsd:decimal ]
] ) ; # this extension maps a numeric score to the code this may already be known and unecessary
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "LA6721-0" ] ;
fhir:display [ fhir:v "Grimace and pulling away, cough, or sneeze during suctioning" ]
] [
fhir:system [ fhir:v "http://acme.ped/apgarreflexirritability"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ]
] ) ;
fhir:text [ fhir:v "2. Grimace and pulling away, cough, or sneeze during suctioning" ]
]
] [
fhir:code [
fhir:coding ( [
a loinc:32413-7 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "32413-7" ] ;
fhir:display [ fhir:v "5 minute Apgar Muscle Tone" ]
] [
a sct:249225007 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "249225007" ] ;
fhir:display [ fhir:v "Apgar muscle tone score" ]
] ) ;
fhir:text [ fhir:v "Apgar muscle tone score" ]
] ;
fhir:value [
a fhir:CodeableConcept ;
fhir:coding ( [
a loinc:LA6715-2 ;
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/itemWeight"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2"^^xsd:decimal ]
] ) ; # this extension maps a numeric score to the code this may already be known and unecessary
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "LA6715-2" ] ;
fhir:display [ fhir:v "Active motion" ]
] [
fhir:system [ fhir:v "http://acme.ped/apgarmuscletone"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ]
] ) ;
fhir:text [ fhir:v "2. Active motion" ]
]
] [
fhir:code [
fhir:coding ( [
a loinc:32415-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "32415-2" ] ;
fhir:display [ fhir:v "5 minute Apgar Respiratory effort" ]
] [
a sct:249224006 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "249224006" ] ;
fhir:display [ fhir:v "Apgar respiratory effort score" ]
] ) ;
fhir:text [ fhir:v "Apgar respiratory effort score" ]
] ;
fhir:value [
a fhir:CodeableConcept ;
fhir:coding ( [
a loinc:LA6727-7 ;
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/itemWeight"^^xsd:anyURI ] ;
fhir:value [ fhir:v "2"^^xsd:decimal ]
] ) ; # this extension maps a numeric score to the code this may already be known and unecessary
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "LA6727-7" ] ;
fhir:display [ fhir:v "Good, strong cry; normal rate and effort of breathing" ]
] [
fhir:system [ fhir:v "http://acme.ped/apgarrespiratoryeffort"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2" ]
] ) ;
fhir:text [ fhir:v "2. Good, strong cry; normal rate and effort of 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.
FHIR ®© HL7.org 2011+. FHIR R5 hl7.fhir.core#5.0.0-draft-final generated on Wed, Mar 1, 2023 23:07+1100.
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