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Example Observation/2minute-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)

Example of a 2 minute Apgar score with individual score as components (id = "2minute-apgar-score")

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

<Observation xmlns="http://hl7.org/fhir">
  <id value="2minute-apgar-score"/> 
  <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="9273-4"/> 
      <display value="2 minute Apgar Score"/> 
    </coding> 
    <text value="2 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="5"/> 
    <system value="http://unitsofmeasure.org"/> 
    <code value="{score}"/> 
  </valueQuantity> 
  <component> 
    <code> 
      <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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6723-6"/> 
        <display value="Good color in body with bluish hands or feet"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarcolor"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Good color in body with bluish hands or feet"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6717-8"/> 
        <display value="Fewer than 100 beats per minute"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarheartrate"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Fewer than 100 beats per minute"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <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="1"/> 
        </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="1"/> 
      </coding> 
      <text value="1. Grimace during suctioning"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6714-5"/> 
        <display value="Some flexion of arms and legs"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarmuscletone"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Some flexion of arms and legs"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <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="1"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6726-9"/> 
        <display value="Weak cry; may sound like whimpering, slow or irregular breathing"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarrespiratoryeffort"/> 
        <code value="1"/> 
      </coding> 
      <text value="1. Weak cry; may sound like whimpering, slow or irregular 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.