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| Orders and Observations Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw JSON (canonical form + also see JSON Format Specification)
Clinical assessment tool example - GCS with individual score as components
{
"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>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>"
},
"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"
}
}
],
"component": [
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "9268-4",
"display": "Glasgow coma score motor"
}
],
"text": "GCS Motor"
},
"valueCodeableConcept": {
"coding": [
{
"system": "http:/acme.ec/codes",
"code": "5",
"display": "Localizes painful stimuli"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/iso21090-ordinal-value",
"valueDecimal": 5
}
],
"system": "http://loinc.org",
"code": "LA6566-9",
"display": "Localizing pain"
}
],
"text": "5 (Localizes painful stimuli)"
}
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "9270-0",
"display": "Glasgow coma score verbal"
}
],
"text": "GSC Verbal"
},
"valueCodeableConcept": {
"coding": [
{
"system": "http:/acme.ec/codes",
"code": "4",
"display": "Confused, disoriented"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/iso21090-ordinal-value",
"valueDecimal": 4
}
],
"system": "http://loinc.org",
"code": "LA6560-2",
"display": "Confused"
}
],
"text": "4 (Confused, disoriented)"
}
},
{
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "9267-6",
"display": "Glasgow coma score eye opening"
}
],
"text": "Eyes"
},
"valueCodeableConcept": {
"coding": [
{
"system": "http:/acme.ec/codes",
"code": "4",
"display": "Opens eyes spontaneously"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/iso21090-ordinal-value",
"valueDecimal": 4
}
],
"system": "http://loinc.org",
"code": "LA6556-0",
"display": "Eyes open spontaneously"
}
],
"text": "4 (Opens eyes spontaneously)"
}
}
]
}
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.