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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 scores as related QuestionnaireAnswer (id = "gcs-qa")
<?xml version="1.0" encoding="UTF-8"?> <Observation xmlns="http://hl7.org/fhir"> <id value="gcs-qa"/> <!-- the mandatory quality flags: --><text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : gcs-qa</p> <p> <b> status</b> : final</p> <p> <b> code</b> : Glasgow Coma Scale , (GCS) <span> (Details : {LOINC code '9269-2' = 'Glasgow coma score total', given as 'Glasgow coma score total'})</span> </p> <p> <b> subject</b> : <a> Peter James Chalmers</a> </p> <p> <b> effective</b> : 11/12/2014 4:44:16 AM</p> <p> <b> value</b> : 13 {score}<span> (Details: UCUM code {score} = '{score}')</span> </p> <blockquote> <p> <b> referenceRange</b> </p> <p> <b> high</b> : 8 {score}<span> (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> type</b> : Severe TBI <span> (Details )</span> </p> </blockquote> <blockquote> <p> <b> referenceRange</b> </p> <p> <b> low</b> : 9 {score}<span> (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> high</b> : 12 {score}<span> (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> type</b> : Moderate TBI <span> (Details )</span> </p> </blockquote> <blockquote> <p> <b> referenceRange</b> </p> <p> <b> low</b> : 13 {score}<span> (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> type</b> : Mild TBI <span> (Details )</span> </p> </blockquote> <p> <b> derivedFrom</b> : <a> GCS form results</a> </p> </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> <!-- put the references to the QuestionnairAnswer example here using the derived-From type --><derivedFrom> <reference value="QuestionnaireResponse/gcs"/> <display value="GCS form results"/> </derivedFrom> </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.