FHIR Release 3 (STU)

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Questionnaire-example-gcs.xml

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Glasgow Coma Score example form (id = "gcs")

<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="gcs"/> 
  <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</p> <p> <b> contained</b> : , , </p> <p> <b> url</b> : <a> http://hl7.org/fhir/Questionnaire/gcs</a> </p> <p> <b> title</b> : Glasgow Coma Score</p> <p> <b> status</b> : draft</p> <p> <b> date</b> : 03/08/2015</p> <p> <b> publisher</b> : FHIR Project team</p> <p> <b> code</b> : Glasgow coma score total (Details: LOINC code 9269-2 = 'Glasgow coma score total', stated
         as 'null')</p> <p> <b> subjectType</b> : Patient</p> <blockquote> <p> <b> item</b> </p> <p> <b> linkId</b> : 1.1</p> <p> <b> code</b> : Glasgow coma score verbal (Details: LOINC code 9270-0 = 'Glasgow coma score verbal',
           stated as 'null')</p> <p> <b> type</b> : choice</p> <p> <b> options</b> : id: verbal; http://loinc.org/ValueSet/LL356-7; name: GCS Verbal Value Set; status: active;
           description: LOINC ANSWER LIST    (LL356-7)</p> </blockquote> <blockquote> <p> <b> item</b> </p> <p> <b> linkId</b> : 1.2</p> <p> <b> code</b> : Glasgow coma score motor (Details: LOINC code 9268-4 = 'Glasgow coma score motor', stated
           as 'null')</p> <p> <b> type</b> : choice</p> <p> <b> options</b> : id: motor; http://loinc.org/ValueSet/LL357-5; name: GCS Motor Value Set; status: active;
           description: LOINC ANSWER LIST    (LL357-5)</p> </blockquote> <blockquote> <p> <b> item</b> </p> <p> <b> linkId</b> : 1.3</p> <p> <b> code</b> : Glasgow coma score eye opening (Details: LOINC code 9267-6 = 'Glasgow coma score eye
           opening', stated as 'null')</p> <p> <b> type</b> : choice</p> <p> <b> options</b> : id: eye; http://loinc.org/ValueSet/LL355-9; name: GCS Eye Value Set; status: active;
           description: LOINC ANSWER LIST    (LL355-9)</p> </blockquote> </div> </text> <contained> 
    <ValueSet> 
      <id value="motor"/> 
      <identifier> 
        <system value="http://loinc.org"/> 
        <value value="http://loinc.org/ValueSet/LL357-5"/> 
      </identifier> 
      <name value="GCS Motor Value Set"/> 
      <status value="active"/> 
      <description value="LOINC ANSWER LIST    (LL357-5)"/> 
      <compose> 
        <include> 
          <system value="http://loinc.org"/> 
          <concept> 
            <code value="LA6562-8"/> 
            <display value="No motor response"/> 
          </concept> 
          <concept> 
            <code value="LA6563-6"/> 
            <display value="Extension to pain"/> 
          </concept> 
          <concept> 
            <code value="LA6564-4"/> 
            <display value="Flexion to pain"/> 
          </concept> 
          <concept> 
            <code value="LA6565-1"/> 
            <display value="Withdrawl from pain"/> 
          </concept> 
          <concept> 
            <code value="LA6566-9"/> 
            <display value="Localizing pain"/> 
          </concept> 
          <concept> 
            <code value="LA6567-7"/> 
            <display value="Obeys commands"/> 
          </concept> 
        </include> 
      </compose> 
    </ValueSet> 
  </contained> 
  <contained> 
    <ValueSet> 
      <id value="verbal"/> 
      <identifier> 
        <system value="http://loinc.org"/> 
        <value value="http://loinc.org/ValueSet/LL356-7"/> 
      </identifier> 
      <name value="GCS Verbal Value Set"/> 
      <status value="active"/> 
      <description value="LOINC ANSWER LIST    (LL356-7)"/> 
      <compose> 
        <include> 
          <system value="http://loinc.org"/> 
          <concept> 
            <code value="LA6557-8"/> 
            <display value="No verbal response (&gt;2yrs); no vocal response (&lt;=2yrs)"/> 
          </concept> 
          <concept> 
            <code value="LA6558-6"/> 
            <display value="Incomprehensible sounds"/> 
          </concept> 
          <concept> 
            <code value="LA6559-4"/> 
            <display value="Inappropriate words"/> 
          </concept> 
          <concept> 
            <code value="LA6560-2"/> 
            <display value="Confused"/> 
          </concept> 
          <concept> 
            <code value="LA6561-0"/> 
            <display value="Oriented"/> 
          </concept> 
        </include> 
      </compose> 
    </ValueSet> 
  </contained> 
  <contained> 
    <ValueSet> 
      <id value="eye"/> 
      <identifier> 
        <system value="http://loinc.org"/> 
        <value value="http://loinc.org/ValueSet/LL355-9"/> 
      </identifier> 
      <name value="GCS Eye Value Set"/> 
      <status value="active"/> 
      <description value="LOINC ANSWER LIST    (LL355-9)"/> 
      <compose> 
        <include> 
          <system value="http://loinc.org"/> 
          <concept> 
            <code value="LA6553-7"/> 
            <display value="No eye opening"/> 
          </concept> 
          <concept> 
            <code value="LA6554-5"/> 
            <display value="Eye opening to pain"/> 
          </concept> 
          <concept> 
            <code value="LA6555-2"/> 
            <display value="Eye opening to verbal command"/> 
          </concept> 
          <concept> 
            <code value="LA6556-0"/> 
            <display value="Eyes open spontaneously"/> 
          </concept> 
        </include> 
      </compose> 
    </ValueSet> 
  </contained> 
  <url value="http://hl7.org/fhir/Questionnaire/gcs"/> 
  <title value="Glasgow Coma Score"/> 
  <status value="draft"/> 
  <date value="2015-08-03"/> 
  <publisher value="FHIR Project team"/> 
  <code> 
    <system value="http://loinc.org"/> 
    <code value="9269-2"/> 
  </code> 
  <subjectType value="Patient"/> 
  <item> 
    <linkId value="1.1"/> 
    <code> 
      <system value="http://loinc.org"/> 
      <code value="9270-0"/> 
    </code> 
    <type value="choice"/> 
    <options> 
      <reference value="#verbal"/> 
    </options> 
  </item> 
  <item> 
    <linkId value="1.2"/> 
    <code> 
      <system value="http://loinc.org"/> 
      <code value="9268-4"/> 
    </code> 
    <type value="choice"/> 
    <options> 
      <reference value="#motor"/> 
    </options> 
  </item> 
  <item> 
    <linkId value="1.3"/> 
    <code> 
      <system value="http://loinc.org"/> 
      <code value="9267-6"/> 
    </code> 
    <type value="choice"/> 
    <options> 
      <reference value="#eye"/> 
    </options> 
  </item> 
</Questionnaire>

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.