R4 Draft for Comment
DiagnosticsThis page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4 R3
| Orders and Observations Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Clinical assessment tool example - GCS with individual score as components
@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <http://loinc.org/rdf#> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
<http://hl7.org/fhir/Observation/glasgow> a fhir:Observation;
fhir:nodeRole fhir:treeRoot;
fhir:Resource.id [ fhir:value "glasgow"];
fhir:DomainResource.text [
fhir:Narrative.status [ fhir:value "generated" ];
fhir:Narrative.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>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>component</b></p><p><b>code</b>: GCS Motor <span>(Details : {LOINC code '9268-4' = 'Glasgow coma score motor', given as 'Glasgow coma score motor'})</span></p><p><b>value</b>: 5 (Localizes painful stimuli) <span>(Details : {http:/acme.ec/codes code '5' = '5', given as 'Localizes painful stimuli'}; {LOINC code 'LA6566-9' = 'Localizing pain', given as 'Localizing pain'})</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: GSC Verbal <span>(Details : {LOINC code '9270-0' = 'Glasgow coma score verbal', given as 'Glasgow coma score verbal'})</span></p><p><b>value</b>: 4 (Confused, disoriented) <span>(Details : {http:/acme.ec/codes code '4' = '4', given as 'Confused, disoriented'}; {LOINC code 'LA6560-2' = 'Confused', given as 'Confused'})</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Eyes <span>(Details : {LOINC code '9267-6' = 'Glasgow coma score eye opening', given as 'Glasgow coma score eye opening'})</span></p><p><b>value</b>: 4 (Opens eyes spontaneously) <span>(Details : {http:/acme.ec/codes code '4' = '4', given as 'Opens eyes spontaneously'}; {LOINC code 'LA6556-0' = 'Eyes open spontaneously', given as 'Eyes open spontaneously'})</span></p></blockquote></div>"
];
fhir:Observation.status [ fhir:value "final"];
fhir:Observation.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:9269-2;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "9269-2" ];
fhir:Coding.display [ fhir:value "Glasgow coma score total" ]
];
fhir:CodeableConcept.text [ fhir:value "Glasgow Coma Scale , (GCS)" ]
];
fhir:Observation.subject [
fhir:link <http://hl7.org/fhir/Patient/example>;
fhir:Reference.reference [ fhir:value "Patient/example" ];
fhir:Reference.display [ fhir:value "Peter James Chalmers" ]
];
fhir:Observation.effectiveDateTime [ fhir:value "2014-12-11T04:44:16Z"^^xsd:dateTime];
fhir:Observation.valueQuantity [
fhir:Quantity.value [ fhir:value "13"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "{score}" ]
];
fhir:Observation.referenceRange [
fhir:index 0;
fhir:Observation.referenceRange.high [
fhir:Quantity.value [ fhir:value "8"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "{score}" ]
];
fhir:Observation.referenceRange.type [
fhir:CodeableConcept.text [ fhir:value "Severe TBI" ]
]
], [
fhir:index 1;
fhir:Observation.referenceRange.low [
fhir:Quantity.value [ fhir:value "9"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "{score}" ]
];
fhir:Observation.referenceRange.high [
fhir:Quantity.value [ fhir:value "12"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "{score}" ]
];
fhir:Observation.referenceRange.type [
fhir:CodeableConcept.text [ fhir:value "Moderate TBI" ]
]
], [
fhir:index 2;
fhir:Observation.referenceRange.low [
fhir:Quantity.value [ fhir:value "13"^^xsd:decimal ];
fhir:Quantity.system [ fhir:value "http://unitsofmeasure.org" ];
fhir:Quantity.code [ fhir:value "{score}" ]
];
fhir:Observation.referenceRange.type [
fhir:CodeableConcept.text [ fhir:value "Mild TBI" ]
]
];
fhir:Observation.component [
fhir:index 0;
fhir:Observation.component.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:9268-4;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "9268-4" ];
fhir:Coding.display [ fhir:value "Glasgow coma score motor" ]
];
fhir:CodeableConcept.text [ fhir:value "GCS Motor" ]
];
fhir:Observation.component.valueCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http:/acme.ec/codes" ];
fhir:Coding.code [ fhir:value "5" ];
fhir:Coding.display [ fhir:value "Localizes painful stimuli" ]
], [
fhir:index 1;
a loinc:LA6566-9;
fhir:Element.extension [
fhir:index 0;
fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/iso21090-CO-value" ];
fhir:Extension.valueDecimal [ fhir:value "5"^^xsd:decimal ]
];
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "LA6566-9" ];
fhir:Coding.display [ fhir:value "Localizing pain" ]
];
fhir:CodeableConcept.text [ fhir:value "5 (Localizes painful stimuli)" ]
]
], [
fhir:index 1;
fhir:Observation.component.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:9270-0;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "9270-0" ];
fhir:Coding.display [ fhir:value "Glasgow coma score verbal" ]
];
fhir:CodeableConcept.text [ fhir:value "GSC Verbal" ]
];
fhir:Observation.component.valueCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http:/acme.ec/codes" ];
fhir:Coding.code [ fhir:value "4" ];
fhir:Coding.display [ fhir:value "Confused, disoriented" ]
], [
fhir:index 1;
a loinc:LA6560-2;
fhir:Element.extension [
fhir:index 0;
fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/iso21090-CO-value" ];
fhir:Extension.valueDecimal [ fhir:value "4"^^xsd:decimal ]
];
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "LA6560-2" ];
fhir:Coding.display [ fhir:value "Confused" ]
];
fhir:CodeableConcept.text [ fhir:value "4 (Confused, disoriented)" ]
]
], [
fhir:index 2;
fhir:Observation.component.code [
fhir:CodeableConcept.coding [
fhir:index 0;
a loinc:9267-6;
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "9267-6" ];
fhir:Coding.display [ fhir:value "Glasgow coma score eye opening" ]
];
fhir:CodeableConcept.text [ fhir:value "Eyes" ]
];
fhir:Observation.component.valueCodeableConcept [
fhir:CodeableConcept.coding [
fhir:index 0;
fhir:Coding.system [ fhir:value "http:/acme.ec/codes" ];
fhir:Coding.code [ fhir:value "4" ];
fhir:Coding.display [ fhir:value "Opens eyes spontaneously" ]
], [
fhir:index 1;
a loinc:LA6556-0;
fhir:Element.extension [
fhir:index 0;
fhir:Extension.url [ fhir:value "http://hl7.org/fhir/StructureDefinition/iso21090-CO-value" ];
fhir:Extension.valueDecimal [ fhir:value "4"^^xsd:decimal ]
];
fhir:Coding.system [ fhir:value "http://loinc.org" ];
fhir:Coding.code [ fhir:value "LA6556-0" ];
fhir:Coding.display [ fhir:value "Eyes open spontaneously" ]
];
fhir:CodeableConcept.text [ fhir:value "4 (Opens eyes spontaneously)" ]
]
] .
<http://hl7.org/fhir/Patient/example> a fhir:Patient .
# - ontology header ------------------------------------------------------------
<http://hl7.org/fhir/Observation/glasgow.ttl> a owl:Ontology;
owl:imports fhir:fhir.ttl;
owl:versionIRI <http://build.fhir.org/Observation/glasgow.ttl> .
# -------------------------------------------------------------------------------------
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.
®© HL7.org 2011+. FHIR Release 4 Draft for Comment (Jan-2018 v3.2.0-12885) generated on Wed, Dec 20, 2017 15:57+1100. QA Page
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