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 |
Raw XML (canonical form + also see XML Format Specification)
Clinical assessment tool example - GCS with individual score as components (id = "glasgow")
<?xml version="1.0" encoding="UTF-8"?> <Observation xmlns="http://hl7.org/fhir"> <id value="glasgow"/> <!-- the mandatory quality flags: --> <text> <status value="generated"/> <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=" 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> <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> </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> <!-- Using components since these measurements are typically reported and interpreted together --> <!-- GCS motor Component --> <component> <code> <coding> <system value="http://loinc.org"/> <code value="9268-4"/> <display value="Glasgow coma score motor"/> </coding> <text value="GCS Motor"/> </code> <valueCodeableConcept> <coding> <system value="http://acme.ec/codes"/> <code value="5"/> <display value="Localizes painful stimuli"/> </coding> <coding> <!-- This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource --> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <!-- from Element: extension --> <valueDecimal value="5"/> <!-- 0..1 Value of extension --> </extension> <system value="http://loinc.org"/> <code value="LA6566-9"/> <display value="Localizing pain"/> </coding> <text value="5 (Localizes painful stimuli)"/> </valueCodeableConcept> </component> <!-- GCS verbal Component --> <component> <code> <coding> <system value="http://loinc.org"/> <code value="9270-0"/> <display value="Glasgow coma score verbal"/> </coding> <text value="GSC Verbal"/> </code> <valueCodeableConcept> <coding> <system value="http://acme.ec/codes"/> <code value="4"/> <display value="Confused, disoriented"/> </coding> <coding> <!-- This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource --> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <!-- from Element: extension --> <valueDecimal value="4"/> <!-- 0..1 Value of extension --> </extension> <system value="http://loinc.org"/> <!-- technicallly the code is '5' and the LA is the identifier to do hav e both would require an extention --> <code value="LA6560-2"/> <display value="Confused"/> </coding> <text value="4 (Confused, disoriented)"/> </valueCodeableConcept> </component> <!-- GCS eyes Component --> <component> <code> <coding> <system value="http://loinc.org"/> <code value="9267-6"/> <display value="Glasgow coma score eye opening"/> </coding> <text value="Eyes"/> </code> <valueCodeableConcept> <coding> <system value="http://acme.ec/codes"/> <code value="4"/> <display value="Opens eyes spontaneously"/> </coding> <coding> <!-- This example has the extension which maps a numeric score to the code this may already be known and unecessary in the Observation resource --> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <!-- from Element: extension --> <valueDecimal value="4"/> <!-- 0..1 Value of extension --> </extension> <system value="http://loinc.org"/> <!-- technicallly the code is '4' and the LA is the identifier to do hav e both would require an extention --> <code value="LA6556-0"/> <display value="Eyes open spontaneously"/> </coding> <text value="4 (Opens eyes spontaneously)"/> </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.
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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