R5 Final QA

This page is part of the FHIR Specification (v5.0.0-draft-final: Final QA Preview for R5 - see ballot notes). 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

Example Observation/5minute-apgar-score (XML)

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Raw XML (canonical form + also see XML Format Specification)

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Example of a 5 minute Apgar score with individual score as components (id = "5minute-apgar-score")

<?xml version="1.0" encoding="UTF-8"?>

<Observation xmlns="http://hl7.org/fhir">
  <id value="5minute-apgar-score"/> 
      <!--     Using a contained patient for the purposes of this example Observation.  Typically
   the reference would be to an external resource     -->
  <text> <status value="generated"/> <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 &quot;5minute-apgar-score&quot; </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 &quot;Apgar at 5 minutes&quot;)</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>  &quot;Adam CAREFUL&quot;</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 &quot;5 minute Apgar Color&quot;; <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 &quot;Good color all over&quot;; 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 &quot;5 minute Apgar Heart Rate&quot;; <a href="https://browser.ihtsdotools.org/">SNOMED CT</a> #249223000 &quot;Apgar heart rate score&quot;)</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 &quot;At least 100 beats per minute&quot;; 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 &quot;5 minute Apgar Reflex Irritability&quot;; <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 &quot;Grimace and pulling away, cough, or sneeze during suctioning&quot;;
             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 &quot;5 minute Apgar Muscle Tone&quot;; <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 &quot;Active motion&quot;; 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 &quot;5 minute Apgar Respiratory effort&quot;; <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 &quot;Good, strong cry; normal rate and effort of breathing&quot;; apgarrespiratory
            effort#2)</span> </p> </blockquote> </div> </text> <contained> 
    <Patient> 
      <id value="newborn"/> 
          <!--      MRN assigned by ACME healthcare on      -->
      <identifier> 
        <system value="http://acmehealthcare/org/mrns"/> 
        <value value="12345"/> 
      </identifier> 
      <active value="true"/> 
          <!--      Peter James Chalmers      -->
      <name> 
        <family value="Chalmers"/> 
        <given value="Peter"/> 
        <given value="James"/> 
      </name> 
          <!--      use FHIR code system for male / female      -->
      <gender value="male"/> 
      <birthDate value="2016-05-18">
        <extension url="http://hl7.org/fhir/StructureDefinition/patient-birthTime">
          <valueDateTime value="2016-05-18T10:28:45Z"/> 
        </extension> 
      </birthDate> 
    </Patient> 
  </contained> 
  <status value="final"/> 
  <category> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/observation-category"/> 
      <code value="survey"/> 
      <display value="Survey"/> 
    </coding> 
    <text value="Survey"/> 
  </category> 
  <code> 
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="9274-2"/> 
      <display value="5 minute Apgar Score"/> 
    </coding> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="169909004"/> 
      <display value="Apgar at 5 minutes"/> 
    </coding> 
    <text value="5 minute Apgar Score"/> 
  </code> 
  <subject> 
    <reference value="#newborn"/> 
  </subject> 
  <effectiveDateTime value="2016-05-18T22:33:22Z"/> 
  <performer> 
    <reference value="Practitioner/example"/> 
  </performer> 
  <valueQuantity> 
    <value value="10"/> 
    <system value="http://unitsofmeasure.org"/> 
    <code value="{score}"/> 
  </valueQuantity> 
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="32411-1"/> 
        <display value="5 minute Apgar Color"/> 
      </coding> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="249227004"/> 
        <display value="Apgar color score"/> 
      </coding> 
      <text value="Apgar color score"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
            <!--   this  extension  maps a numeric score to the code this may already be known and
         unecessary   -->
        <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight">
          <valueDecimal value="2"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6724-4"/> 
        <display value="Good color all over"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarcolor"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. Good color all over"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="32412-9"/> 
        <display value="5 minute Apgar Heart Rate"/> 
      </coding> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="249223000"/> 
        <display value="Apgar heart rate score"/> 
      </coding> 
      <text value="Apgar respiratory effort score"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
            <!--   this  extension  maps a numeric score to the code this may already be known and
         unecessary   -->
        <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight">
          <valueDecimal value="2"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6718-6"/> 
        <display value="At least 100 beats per minute"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarheartrate"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. At least 100 beats per minute"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="32414-5"/> 
        <display value="5 minute Apgar Reflex Irritability"/> 
      </coding> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="249226008"/> 
        <display value="Apgar response to stimulus score"/> 
      </coding> 
      <text value="Apgar response to stimulus score"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
            <!--   this  extension  maps a numeric score to the code this may already be known and
         unecessary   -->
        <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight">
          <valueDecimal value="2"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6721-0"/> 
        <display value="Grimace and pulling away, cough, or sneeze during suctioning"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarreflexirritability"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. Grimace and pulling away, cough, or sneeze during suctioning"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="32413-7"/> 
        <display value="5 minute Apgar Muscle Tone"/> 
      </coding> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="249225007"/> 
        <display value="Apgar muscle tone score"/> 
      </coding> 
      <text value="Apgar muscle tone score"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
            <!--   this  extension  maps a numeric score to the code this may already be known and
         unecessary   -->
        <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight">
          <valueDecimal value="2"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6715-2"/> 
        <display value="Active motion"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarmuscletone"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. Active motion"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="32415-2"/> 
        <display value="5 minute Apgar Respiratory effort"/> 
      </coding> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="249224006"/> 
        <display value="Apgar respiratory effort score"/> 
      </coding> 
      <text value="Apgar respiratory effort score"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
            <!--   this  extension  maps a numeric score to the code this may already be known and
         unecessary   -->
        <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight">
          <valueDecimal value="2"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6727-7"/> 
        <display value="Good, strong cry; normal rate and effort of breathing"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarrespiratoryeffort"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. Good, strong cry; normal rate and effort of breathing"/> 
    </valueCodeableConcept> 
  </component> 
</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.