This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3
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 scores as related QuestionnaireAnswer
@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 "gcs-qa"] ; # 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=\"gcs-qa\"> </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 "gcs-qa" </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><p><b>derivedFrom</b>: <span title=\" put the references to the QuestionnairAnswer example here using the derived-From type \"><a href=\"questionnaireresponse-example-gcs.html\">QuestionnaireResponse/gcs: GCS form results</a></span></p></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:derivedFrom ( [ fhir:reference [ fhir:v "QuestionnaireResponse/gcs" ] ; fhir:display [ fhir:v "GCS form results" ] ] )] . # put the references to the QuestionnairAnswer example here using the derived-From type # -------------------------------------------------------------------------------------
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.
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