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Orders and Observations Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Clinical assessment tool example - GCS using related Observations
{ "resourceType": "Observation", "id": "glasgow", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: glasgow</p><p><b>contained</b>: , , </p><p><b>status</b>: final</p><p><b>code</b>: Glasgow Coma Scale , (GCS) <span>(Details : {LOINC code '9269-2' = 'Glasgow coma score total', given as 'Glasgow coma score total'})</span></p><p><b>subject</b>: <a>Peter James Chalmers</a></p><p><b>effective</b>: 11/12/2014 4:44:16 AM</p><p><b>value</b>: 13 {score}<span> (Details: UCUM code {score} = '{score}')</span></p><blockquote><p><b>referenceRange</b></p><p><b>high</b>: 8 {score}<span> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Severe TBI <span>(Details )</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 9 {score}<span> (Details: UCUM code {score} = '{score}')</span></p><p><b>high</b>: 12 {score}<span> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Moderate TBI <span>(Details )</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 13 {score}<span> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Mild TBI <span>(Details )</span></p></blockquote><blockquote><p><b>related</b></p><p><b>type</b>: derived-from</p><p><b>target</b>: Motor score. Generated Summary: id: motor; status: final; GCS motor <span>(Details : {LOINC code '9268-4' = 'Glasgow coma score motor', given as 'Glasgow coma score motor'})</span>; ????; effective: 11/12/2014 4:44:16 AM; 5 (Localizes painful stimuli) <span>(Details : {http:/acme.ec/gcsmotor code '5' = '5', given as 'Localizes painful stimuli'}; {LOINC code 'LA6566-9' = 'Localizing pain', given as 'Localizing pain'})</span></p></blockquote><blockquote><p><b>related</b></p><p><b>type</b>: derived-from</p><p><b>target</b>: Verbal score. Generated Summary: id: verbal; status: final; Verbal <span>(Details : {LOINC code '9270-0' = 'Glasgow coma score verbal', given as 'Glasgow coma score verbal'})</span>; ????; effective: 11/12/2014 4:44:16 AM; 4 (Confused, disoriented) <span>(Details : {http:/acme.ec/gcsverbal code '4' = '4', given as 'Confused, disoriented'}; {LOINC code 'LA6560-2' = 'Confused', given as 'Confused'})</span></p></blockquote><blockquote><p><b>related</b></p><p><b>type</b>: derived-from</p><p><b>target</b>: Eyes score. Generated Summary: id: eyes; status: final; Eyes <span>(Details : {LOINC code '9267-6' = 'Glasgow coma score eye opening', given as 'Glasgow coma score eye opening'})</span>; ????; effective: 11/12/2014 4:44:16 AM; 4 (Opens eyes spontaneously) <span>(Details : {http:/acme.ec/gcseye code '4' = '4', given as 'Opens eyes spontaneously'}; {LOINC code 'LA6556-0' = 'Eyes open spontaneously', given as 'Eyes open spontaneously'})</span></p></blockquote></div>" }, "contained": [ { "resourceType": "Observation", "id": "motor", "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "9268-4", "display": "Glasgow coma score motor" } ], "text": "GCS motor" }, "subject": { "reference": "Patient/example" }, "effectiveDateTime": "2014-12-11T04:44:16Z", "valueCodeableConcept": { "coding": [ { "system": "http:/acme.ec/gcsmotor", "code": "5", "display": "Localizes painful stimuli" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/iso21090-CO-value", "valueDecimal": 5 } ], "system": "http://loinc.org", "code": "LA6566-9", "display": "Localizing pain" } ], "text": "5 (Localizes painful stimuli)" } }, { "resourceType": "Observation", "id": "verbal", "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "9270-0", "display": "Glasgow coma score verbal" } ], "text": "Verbal" }, "subject": { "reference": "Patient/example" }, "effectiveDateTime": "2014-12-11T04:44:16Z", "valueCodeableConcept": { "coding": [ { "system": "http:/acme.ec/gcsverbal", "code": "4", "display": "Confused, disoriented" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/iso21090-CO-value", "valueDecimal": 4 } ], "system": "http://loinc.org", "code": "LA6560-2", "display": "Confused" } ], "text": "4 (Confused, disoriented)" } }, { "resourceType": "Observation", "id": "eyes", "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "9267-6", "display": "Glasgow coma score eye opening" } ], "text": "Eyes" }, "subject": { "reference": "Patient/example" }, "effectiveDateTime": "2014-12-11T04:44:16Z", "valueCodeableConcept": { "coding": [ { "system": "http:/acme.ec/gcseye", "code": "4", "display": "Opens eyes spontaneously" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/iso21090-CO-value", "valueDecimal": 4 } ], "system": "http://loinc.org", "code": "LA6556-0", "display": "Eyes open spontaneously" } ], "text": "4 (Opens eyes spontaneously)" } } ], "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "9269-2", "display": "Glasgow coma score total" } ], "text": "Glasgow Coma Scale , (GCS)" }, "subject": { "reference": "Patient/example", "display": "Peter James Chalmers" }, "effectiveDateTime": "2014-12-11T04:44:16Z", "valueQuantity": { "value": 13, "system": "http://unitsofmeasure.org", "code": "{score}" }, "referenceRange": [ { "high": { "value": 8, "system": "http://unitsofmeasure.org", "code": "{score}" }, "type": { "text": "Severe TBI" } }, { "low": { "value": 9, "system": "http://unitsofmeasure.org", "code": "{score}" }, "high": { "value": 12, "system": "http://unitsofmeasure.org", "code": "{score}" }, "type": { "text": "Moderate TBI" } }, { "low": { "value": 13, "system": "http://unitsofmeasure.org", "code": "{score}" }, "type": { "text": "Mild TBI" } } ], "related": [ { "type": "derived-from", "target": { "reference": "#motor", "display": "Motor score" } }, { "type": "derived-from", "target": { "reference": "#verbal", "display": "Verbal score" } }, { "type": "derived-from", "target": { "reference": "#eyes", "display": "Eyes score" } } ] }
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.