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Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw JSON (canonical form + also see JSON Format Specification)
Example of a 10 minute Apgar score with individual score as components
{ "resourceType": "Observation", "id": "10minute-apgar-score", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: 10minute-apgar-score</p><p><b>contained</b>: </p><p><b>status</b>: final</p><p><b>category</b>: Survey <span>(Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'survey' = 'Survey', given as 'Survey'})</span></p><p><b>code</b>: 10 minute Apgar Score <span>(Details : {LOINC code '9271-8' = '10 minute Apgar Score', given as '10 minute Apgar Score'}; {SNOMED CT code '169922007' = 'Apgar at 10 minutes', given as 'Apgar at 10 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 : {LOINC code '32401-2' = '10 minute Apgar Color', given as '10 minute Apgar Color'}; {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 : {LOINC code 'LA6724-4' = 'Good color all over', 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 : {LOINC code '32402-0' = '10 minute Apgar Heart rate', given as '10 minute Apgar Heart Rate'}; {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 : {LOINC code 'LA6718-6' = 'At least 100 beats per minute', 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 : {LOINC code '32404-6' = '10 minute Apgar Reflex irritability', given as '10 minute Apgar Reflex Irritability'}; {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 : {LOINC code 'LA6721-0' = 'Grimace and pulling away, cough, or sneeze during suctioning', 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 : {LOINC code '32403-8' = '10 minute Apgar Muscle tone', given as '10 minute Apgar Muscle Tone'}; {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 : {LOINC code 'LA6715-2' = 'Active motion', 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 : {LOINC code '32405-3' = '10 minute Apgar Respiratory effort', given as '10 minute Apgar Respiratory effort'}; {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 : {LOINC code 'LA6727-7' = 'Good, strong cry; normal rate and effort of breathing', given as 'Good, strong cry; normal rate and effort of breathing '}; {http://acme.ped/apgarrespiratoryeffort code '2' = '2)</span></p></blockquote></div>" }, "contained": [ { "resourceType": "Patient", "id": "newborn", "identifier": [ { "system": "http://acmehealthcare/org/mrns", "value": "12345" } ], "active": true, "name": [ { "family": "Chalmers", "given": [ "Peter", "James" ] } ], "gender": "male", "birthDate": "2016-05-18", "_birthDate": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/patient-birthTime", "valueDateTime": "2016-05-18T10:28:45Z" } ] } } ], "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "survey", "display": "Survey" } ], "text": "Survey" } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "9271-8", "display": "10 minute Apgar Score" }, { "system": "http://snomed.info/sct", "code": "169922007", "display": "Apgar at 10 minutes" } ], "text": "10 minute Apgar Score" }, "subject": { "reference": "#newborn" }, "effectiveDateTime": "2016-05-18T22:33:22Z", "performer": [ { "reference": "Practitioner/example" } ], "valueQuantity": { "value": 10, "system": "http://unitsofmeasure.org", "code": "{score}" }, "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "32401-2", "display": "10 minute Apgar Color" }, { "system": "http://snomed.info/sct", "code": "249227004", "display": "Apgar color score" } ], "text": "Apgar color score" }, "valueCodeableConcept": { "coding": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue", "valueDecimal": 2 } ], "system": "http://loinc.org", "code": "LA6724-4", "display": "Good color all over" }, { "system": "http://acme.ped/apgarcolor", "code": "2" } ], "text": "2. Good color all over" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32402-0", "display": "10 minute Apgar Heart Rate" }, { "system": "http://snomed.info/sct", "code": "249223000", "display": "Apgar heart rate score" } ], "text": "Apgar respiratory effort score" }, "valueCodeableConcept": { "coding": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue", "valueDecimal": 2 } ], "system": "http://loinc.org", "code": "LA6718-6", "display": "At least 100 beats per minute" }, { "system": "http://acme.ped/apgarheartrate", "code": "2" } ], "text": "2. At least 100 beats per minute" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32404-6", "display": "10 minute Apgar Reflex Irritability" }, { "system": "http://snomed.info/sct", "code": "249226008", "display": "Apgar response to stimulus score" } ], "text": "Apgar response to stimulus score" }, "valueCodeableConcept": { "coding": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue", "valueDecimal": 2 } ], "system": "http://loinc.org", "code": "LA6721-0", "display": "Grimace and pulling away, cough, or sneeze during suctioning" }, { "system": "http://acme.ped/apgarreflexirritability", "code": "2" } ], "text": "2. Grimace and pulling away, cough, or sneeze during suctioning" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32403-8", "display": "10 minute Apgar Muscle Tone" }, { "system": "http://snomed.info/sct", "code": "249225007", "display": "Apgar muscle tone score" } ], "text": "Apgar muscle tone score" }, "valueCodeableConcept": { "coding": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue", "valueDecimal": 2 } ], "system": "http://loinc.org", "code": "LA6715-2", "display": "Active motion " }, { "system": "http://acme.ped/apgarmuscletone", "code": "2" } ], "text": "2. Active motion" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32405-3", "display": "10 minute Apgar Respiratory effort" }, { "system": "http://snomed.info/sct", "code": "249224006", "display": "Apgar respiratory effort score" } ], "text": "Apgar respiratory effort score" }, "valueCodeableConcept": { "coding": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue", "valueDecimal": 2 } ], "system": "http://loinc.org", "code": "LA6727-7", "display": "Good, strong cry; normal rate and effort of breathing " }, { "system": "http://acme.ped/apgarrespiratoryeffort", "code": "2" } ], "text": "2. Good, strong cry; normal rate and effort of breathing" } } ] }
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.