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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 5 minute Apgar score with individual score as components
{ "resourceType" : "Observation", "id" : "5minute-apgar-score", "text" : { "status" : "generated", "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: Observation</b><a name=\"5minute-apgar-score\"> </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 "5minute-apgar-score" </p></div><p><b>status</b>: final</p><p><b>category</b>: Survey <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"http://terminology.hl7.org/5.1.0/CodeSystem-observation-category.html\">Observation Category Codes</a>#survey)</span></p><p><b>code</b>: 5 minute Apgar Score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9274-2; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#169909004 "Apgar at 5 minutes")</span></p><p><b>subject</b>: <a name=\"newborn\"> </a></p><blockquote><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\"><b>Peter James Chalmers </b> male, DoB: 2016-05-18 ( id:\u00a012345)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Record is active\">Active:</td><td colspan=\"3\">true</td></tr></table></blockquote><p><b>effective</b>: 2016-05-18T22:33:22Z</p><p><b>performer</b>: <a href=\"practitioner-example.html\">Practitioner/example</a> "Adam CAREFUL"</p><p><b>value</b>: 10 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><blockquote><p><b>component</b></p><p><b>code</b>: Apgar color score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#32411-1 "5 minute Apgar Color"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249227004)</span></p><p><b>value</b>: 2. Good color all over <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6724-4 "Good color all over"; apgarcolor#2)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar respiratory effort score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#32412-9 "5 minute Apgar Heart Rate"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249223000 "Apgar heart rate score")</span></p><p><b>value</b>: 2. At least 100 beats per minute <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6718-6 "At least 100 beats per minute"; apgarheartrate#2)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar response to stimulus score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#32414-5 "5 minute Apgar Reflex Irritability"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249226008)</span></p><p><b>value</b>: 2. Grimace and pulling away, cough, or sneeze during suctioning <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6721-0 "Grimace and pulling away, cough, or sneeze during suctioning"; apgarreflexirritability#2)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar muscle tone score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#32413-7 "5 minute Apgar Muscle Tone"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249225007)</span></p><p><b>value</b>: 2. Active motion <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6715-2 "Active motion"; apgarmuscletone#2)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar respiratory effort score <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#32415-2 "5 minute Apgar Respiratory effort"; <a href=\"https://browser.ihtsdotools.org/\">SNOMED CT</a>#249224006)</span></p><p><b>value</b>: 2. Good, strong cry; normal rate and effort of breathing <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#LA6727-7 "Good, strong cry; normal rate and effort of breathing"; apgarrespiratoryeffort#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" : "9274-2", "display" : "5 minute Apgar Score" }, { "system" : "http://snomed.info/sct", "code" : "169909004", "display" : "Apgar at 5 minutes" }], "text" : "5 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" : "32411-1", "display" : "5 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/itemWeight", "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" : "32412-9", "display" : "5 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/itemWeight", "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" : "32414-5", "display" : "5 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/itemWeight", "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" : "32413-7", "display" : "5 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/itemWeight", "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" : "32415-2", "display" : "5 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/itemWeight", "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.
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