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Observation-example-20minute-apgar-score.xml

Orders and Observations Work Group
Maturity Level: N/A
Ballot Status: Informative
Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson
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Example of a 20 minute Apgar score including the individual score components (id = "20minute-apgar-score")
<Observation xmlns="http://hl7.org/fhir">
  <id value="20minute-apgar-score"/> 
  <!--     Using a contained patient for the purposes of this example Observation.  Typically
   the reference would be to an external resource     -->
  <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : 20minute-apgar-score</p> <p> <b> contained</b> : </p> <p> <b> status</b> : final</p> <p> <b> category</b> : Survey <span> (Details : {http://hl7.org/fhir/observation-category code 'survey' = 'Survey', given as
           'Survey'})</span> </p> <p> <b> code</b> : 20 minute Apgar Score <span> (Details : {SNOMED CT code '443849008' = 'Apgar score at 20 minutes', given as 'Apgar
           score at 20 minutes'})</span> </p> <p> <b> subject</b> : id: newborn; 12345; active; Peter James Chalmers ; gender: male; birthDate: 18/05/2016</p> <p> <b> effective</b> : 18/05/2016 10:33:22 PM</p> <p> <b> performer</b> : <a> Practitioner/example</a> </p> <p> <b> value</b> : 10 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar color score <span> (Details : {SNOMED CT code '249227004' = 'Apgar color score', given as 'Apgar color score'})</span> </p> <p> <b> value</b> : 2. Good color all over <span> (Details : {http://loinc.org/la code 'LA6724-4' = 'LA6724-4', given as 'Good color all
             over'}; {http:/acme.ped/apgarcolor code '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span> (Details : {SNOMED CT code '249223000' = 'Apgar heart rate score', given as 'Apgar heart
             rate score'})</span> </p> <p> <b> value</b> : 2. At least 100 beats per minute <span> (Details : {http://loinc.org/la code 'LA6718-6' = 'LA6718-6', given as 'At least 100 beats
             per minute'}; {http:/acme.ped/apgarheartrate code '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar response to stimulus score <span> (Details : {SNOMED CT code '249226008' = 'Apgar response to stimulus score', given as
             'Apgar response to stimulus score'})</span> </p> <p> <b> value</b> : 2. Grimace and pulling away, cough, or sneeze during suctioning <span> (Details : {http://loinc.org/la code 'LA6721-0' = 'LA6721-0', given as 'Grimace and pulling
             away, cough, or sneeze during suctioning'}; {http:/acme.ped/apgarreflexirritability code
             '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar muscle tone score <span> (Details : {SNOMED CT code '249225007' = 'Apgar muscle tone score', given as 'Apgar muscle
             tone score'})</span> </p> <p> <b> value</b> : 2. Active motion <span> (Details : {http://loinc.org/la code 'LA6715-2' = 'LA6715-2', given as 'Active motion
             '}; {http:/acme.ped/apgarmuscletone code '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span> (Details : {SNOMED CT code '249224006' = 'Apgar respiratory effort score', given as 'Apgar
             respiratory effort score'})</span> </p> <p> <b> value</b> : 2. Good, strong cry; normal rate and effort of breathing <span> (Details : {http://loinc.org/la code 'LA6727-7' = 'LA6727-7', given as 'Good, strong cry;
             normal rate and effort of breathing    '}; {http:/acme.ped/apgarrespiratoryeffort code
             '2' = '2)</span> </p> </blockquote> </div> </text> <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://hl7.org/fhir/observation-category"/> 
      <code value="survey"/> 
      <display value="Survey"/> 
    </coding> 
    <text value="Survey"/> 
  </category> 
  <code> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="443849008"/> 
      <display value="Apgar score at 20 minutes"/> 
    </coding> 
    <text value="20 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="10"/> 
    <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/iso21090-CO-value">
          <valueDecimal value="2"/> 
        </extension> 
        <system value="http://loinc.org/la"/> 
        <code value="LA6724-4"/> 
        <display value="Good color all over"/> 
      </coding> 
      <coding> 
        <system value="http:/acme.ped/apgarcolor"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. Good color all over"/> 
    </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/iso21090-CO-value">
          <valueDecimal value="2"/> 
        </extension> 
        <system value="http://loinc.org/la"/> 
        <code value="LA6718-6"/> 
        <display value="At least 100 beats per minute"/> 
      </coding> 
      <coding> 
        <system value="http:/acme.ped/apgarheartrate"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. At least 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/iso21090-CO-value">
          <valueDecimal value="2"/> 
        </extension> 
        <system value="http://loinc.org/la"/> 
        <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="2"/> 
      </coding> 
      <text value="2. Grimace and pulling away, cough, or sneeze 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/iso21090-CO-value">
          <valueDecimal value="2"/> 
        </extension> 
        <system value="http://loinc.org/la"/> 
        <code value="LA6715-2"/> 
        <display value="Active motion "/> 
      </coding> 
      <coding> 
        <system value="http:/acme.ped/apgarmuscletone"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. Active motion"/> 
    </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/iso21090-CO-value">
          <valueDecimal value="2"/> 
        </extension> 
        <system value="http://loinc.org/la"/> 
        <code value="LA6727-7"/> 
        <display value="Good, strong cry; normal rate and effort of breathing    "/> 
      </coding> 
      <coding> 
        <system value="http:/acme.ped/apgarrespiratoryeffort"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. Good, strong cry; normal rate and effort of 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.