R5 Final QA
DiagnosticsThis 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 
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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: <https://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:id [ fhir:v "glasgow"] ; #
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=\"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>"
] ; # the mandatory quality flags:
fhir:status [ fhir:v "final"] ; #
fhir:code [
fhir:coding ( [
a loinc:9269-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "9269-2" ] ;
fhir:display [ fhir:v "Glasgow coma score total" ]
] ) ; # LOINC - always recommended to have a LOINC code
fhir:text [ fhir:v "Glasgow Coma Scale , (GCS)" ]
] ; #
# 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
#
fhir:subject [
fhir:reference [ fhir:v "Patient/example" ] ;
fhir:display [ fhir:v "Peter James Chalmers" ]
] ; #
fhir:effective [ fhir:v "2014-12-11T04:44:16Z"^^xsd:dateTime] ; #
fhir:value [
a fhir:Quantity ;
fhir:value [ fhir:v "13"^^xsd:decimal ] ;
fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "{score}" ]
] ; # 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
#
fhir:referenceRange ( [
fhir:high [
fhir:value [ fhir:v "8"^^xsd:decimal ] ;
fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "{score}" ]
] ;
fhir:type [
fhir:text [ fhir:v "Severe TBI" ]
] # meaning as text
] [
fhir:low [
fhir:value [ fhir:v "9"^^xsd:decimal ] ;
fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "{score}" ]
] ;
fhir:high [
fhir:value [ fhir:v "12"^^xsd:decimal ] ;
fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "{score}" ]
] ;
fhir:type [
fhir:text [ fhir:v "Moderate TBI" ]
] # meaning as text
] [
fhir:low [
fhir:value [ fhir:v "13"^^xsd:decimal ] ;
fhir:system [ fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "{score}" ]
] ;
fhir:type [
fhir:text [ fhir:v "Mild TBI" ]
] # meaning as text
] ) ; #
fhir:component ( [
fhir:code [
fhir:coding ( [
a loinc:9268-4 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "9268-4" ] ;
fhir:display [ fhir:v "Glasgow coma score motor" ]
] ) ;
fhir:text [ fhir:v "GCS Motor" ]
] ;
fhir:value [
a fhir:CodeableConcept ;
fhir:coding ( [
fhir:system [ fhir:v "http://acme.ec/codes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "5" ] ;
fhir:display [ fhir:v "Localizes painful stimuli" ]
] [
a loinc:LA6566-9 ;
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/itemWeight"^^xsd:anyURI ] ;
fhir:value [ fhir:v "5"^^xsd:decimal ] # from Element: extension
] ) ; # This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource , 0..1 Value of extension
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "LA6566-9" ] ;
fhir:display [ fhir:v "Localizing pain" ]
] ) ;
fhir:text [ fhir:v "5 (Localizes painful stimuli)" ]
]
] [
fhir:code [
fhir:coding ( [
a loinc:9270-0 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "9270-0" ] ;
fhir:display [ fhir:v "Glasgow coma score verbal" ]
] ) ;
fhir:text [ fhir:v "GSC Verbal" ]
] ;
fhir:value [
a fhir:CodeableConcept ;
fhir:coding ( [
fhir:system [ fhir:v "http://acme.ec/codes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "4" ] ;
fhir:display [ fhir:v "Confused, disoriented" ]
] [
a loinc:LA6560-2 ;
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/itemWeight"^^xsd:anyURI ] ;
fhir:value [ fhir:v "4"^^xsd:decimal ] # from Element: extension
] ) ; # This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource , 0..1 Value of extension
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "LA6560-2" ] ; # technicallly the code is '5' and the LA is the identifier to do hav e both would require an extention
fhir:display [ fhir:v "Confused" ]
] ) ;
fhir:text [ fhir:v "4 (Confused, disoriented)" ]
]
] [
fhir:code [
fhir:coding ( [
a loinc:9267-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "9267-6" ] ;
fhir:display [ fhir:v "Glasgow coma score eye opening" ]
] ) ;
fhir:text [ fhir:v "Eyes" ]
] ;
fhir:value [
a fhir:CodeableConcept ;
fhir:coding ( [
fhir:system [ fhir:v "http://acme.ec/codes"^^xsd:anyURI ] ;
fhir:code [ fhir:v "4" ] ;
fhir:display [ fhir:v "Opens eyes spontaneously" ]
] [
a loinc:LA6556-0 ;
fhir:extension ( [
fhir:url [ fhir:v "http://hl7.org/fhir/StructureDefinition/itemWeight"^^xsd:anyURI ] ;
fhir:value [ fhir:v "4"^^xsd:decimal ] # from Element: extension
] ) ; # This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource , 0..1 Value of extension
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "LA6556-0" ] ; # technicallly the code is '4' and the LA is the identifier to do hav e both would require an extention
fhir:display [ fhir:v "Eyes open spontaneously" ]
] ) ;
fhir:text [ fhir:v "4 (Opens eyes spontaneously)" ]
]
] )] . # Using components since these measurements are typically reported and interpreted together , GCS motor Component
# -------------------------------------------------------------------------------------
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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