This is Snapshot #3 for FHIR R5, released to support Connectathon 32. For a full list of available versions, see the Directory of published versions.
Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw JSON (canonical form + also see JSON Format Specification)
Clinical assessment tool example - GCS with individual score as components
{ "resourceType" : "Observation", "id" : "glasgow", "text" : { "status" : "generated", "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\t\t- or SNOMED\n -and/or the source system may provides its own "local" code, which may be less or more granular than LOINC.\n\tIn 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>" }, "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "9269-2", "display" : "Glasgow coma score total" }], "text" : "Glasgow Coma Scale , (GCS)" }, "subject" : { "reference" : "Patient/example", "display" : "Peter James Chalmers" }, "effectiveDateTime" : "2014-12-11T04:44:16Z", "valueQuantity" : { "value" : 13, "system" : "http://unitsofmeasure.org", "code" : "{score}" }, "referenceRange" : [{ "high" : { "value" : 8, "system" : "http://unitsofmeasure.org", "code" : "{score}" }, "type" : { "text" : "Severe TBI" } }, { "low" : { "value" : 9, "system" : "http://unitsofmeasure.org", "code" : "{score}" }, "high" : { "value" : 12, "system" : "http://unitsofmeasure.org", "code" : "{score}" }, "type" : { "text" : "Moderate TBI" } }, { "low" : { "value" : 13, "system" : "http://unitsofmeasure.org", "code" : "{score}" }, "type" : { "text" : "Mild TBI" } }], "component" : [{ "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "9268-4", "display" : "Glasgow coma score motor" }], "text" : "GCS Motor" }, "valueCodeableConcept" : { "coding" : [{ "system" : "http://acme.ec/codes", "code" : "5", "display" : "Localizes painful stimuli" }, { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/itemWeight", "valueDecimal" : 5 }], "system" : "http://loinc.org", "code" : "LA6566-9", "display" : "Localizing pain" }], "text" : "5 (Localizes painful stimuli)" } }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "9270-0", "display" : "Glasgow coma score verbal" }], "text" : "GSC Verbal" }, "valueCodeableConcept" : { "coding" : [{ "system" : "http://acme.ec/codes", "code" : "4", "display" : "Confused, disoriented" }, { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/itemWeight", "valueDecimal" : 4 }], "system" : "http://loinc.org", "code" : "LA6560-2", "display" : "Confused" }], "text" : "4 (Confused, disoriented)" } }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "9267-6", "display" : "Glasgow coma score eye opening" }], "text" : "Eyes" }, "valueCodeableConcept" : { "coding" : [{ "system" : "http://acme.ec/codes", "code" : "4", "display" : "Opens eyes spontaneously" }, { "extension" : [{ "url" : "http://hl7.org/fhir/StructureDefinition/itemWeight", "valueDecimal" : 4 }], "system" : "http://loinc.org", "code" : "LA6556-0", "display" : "Eyes open spontaneously" }], "text" : "4 (Opens eyes spontaneously)" } }] }
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-snapshot3 generated on Wed, Dec 14, 2022 07:17+1100.
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