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Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
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Example of a 1 minute Apgar score with individual score as components
{ "resourceType": "Observation", "id": "1minute-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>: 1minute-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>: 1 minute Apgar Score <span>(Details : {LOINC code '9272-6' = '1 minute Apgar Score', given as '1 minute Apgar Score'}; {SNOMED CT code '169895004' = 'Apgar at 1 minute', given as 'Apgar at 1 minute'})</span></p><p><b>subject</b>: id: newborn; 12345; active; Peter James Chalmers ; gender: male; birthDate: 2016-05-18</p><p><b>effective</b>: 18 May 2016, 10:33:22 pm</p><p><b>performer</b>: <a>Practitioner/example</a></p><p><b>value</b>: 0 {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 '32406-1' = '1 minute Apgar Color', given as '1 minute Apgar Color'}; {SNOMED CT code '249227004' = 'Apgar color score', given as 'Apgar color score'})</span></p><p><b>value</b>: 0. The baby's whole body is completely bluish-gray or pale <span>(Details : {LOINC code 'LA6722-8' = 'The baby's whole body is completely bluish-gray or pale', given as 'The baby's whole body is completely bluish-gray or pale'}; {http://acme.ped/apgarcolor code '0' = '0)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar respiratory effort score <span>(Details : {LOINC code '32407-9' = '1 minute Apgar Heart rate', given as '1 minute Apgar Heart Rate'}; {SNOMED CT code '249223000' = 'Apgar heart rate score', given as 'Apgar heart rate score'})</span></p><p><b>value</b>: 0. No heart rate <span>(Details : {LOINC code 'LA6716-0' = 'No heart rate', given as 'No heart rate'}; {http://acme.ped/apgarheartrate code '0' = '0)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar response to stimulus score <span>(Details : {LOINC code '32409-5' = '1 minute Apgar Reflex irritability', given as '1 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>: 0. No response to airways being suctioned <span>(Details : {LOINC code 'LA6719-4' = 'No response to airways being suctioned', given as 'No response to airways being suctioned'}; {http://acme.ped/apgarreflexirritability code '0' = '0)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar muscle tone score <span>(Details : {LOINC code '32408-7' = '1 minute Apgar Muscle tone', given as '1 minute Apgar Muscle Tone'}; {SNOMED CT code '249225007' = 'Apgar muscle tone score', given as 'Apgar muscle tone score'})</span></p><p><b>value</b>: 0. Limp; no movement <span>(Details : {LOINC code 'LA6713-7' = 'Limp; no movement', given as 'Limp; no movement'}; {http://acme.ped/apgarmuscletone code '0' = '0)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Apgar respiratory effort score <span>(Details : {LOINC code '32410-3' = '1 minute Apgar Respiratory effort', given as '1 minute Apgar Respiratory effort'}; {SNOMED CT code '249224006' = 'Apgar respiratory effort score', given as 'Apgar respiratory effort score'})</span></p><p><b>value</b>: 0. Not breathing <span>(Details : {LOINC code 'LA6725-1' = 'Not breathing', given as 'Not breathing'}; {http://acme.ped/apgarrespiratoryeffort code '0' = '0)</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": "9272-6", "display": "1 minute Apgar Score" }, { "system": "http://snomed.info/sct", "code": "169895004", "display": "Apgar at 1 minute" } ], "text": "1 minute Apgar Score" }, "subject": { "reference": "#newborn" }, "effectiveDateTime": "2016-05-18T22:33:22Z", "performer": [ { "reference": "Practitioner/example" } ], "valueQuantity": { "value": 0, "system": "http://unitsofmeasure.org", "code": "{score}" }, "component": [ { "code": { "coding": [ { "system": "http://loinc.org", "code": "32406-1", "display": "1 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": 0 } ], "system": "http://loinc.org", "code": "LA6722-8", "display": "The baby's whole body is completely bluish-gray or pale" }, { "system": "http://acme.ped/apgarcolor", "code": "0" } ], "text": "0. The baby's whole body is completely bluish-gray or pale" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32407-9", "display": "1 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": 0 } ], "system": "http://loinc.org", "code": "LA6716-0", "display": "No heart rate" }, { "system": "http://acme.ped/apgarheartrate", "code": "0" } ], "text": "0. No heart rate" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32409-5", "display": "1 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": 0 } ], "system": "http://loinc.org", "code": "LA6719-4", "display": "No response to airways being suctioned" }, { "system": "http://acme.ped/apgarreflexirritability", "code": "0" } ], "text": "0. No response to airways being suctioned" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32408-7", "display": "1 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": 0 } ], "system": "http://loinc.org", "code": "LA6713-7", "display": "Limp; no movement" }, { "system": "http://acme.ped/apgarmuscletone", "code": "0" } ], "text": "0. Limp; no movement" } }, { "code": { "coding": [ { "system": "http://loinc.org", "code": "32410-3", "display": "1 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": 0 } ], "system": "http://loinc.org", "code": "LA6725-1", "display": "Not breathing" }, { "system": "http://acme.ped/apgarrespiratoryeffort", "code": "0" } ], "text": "0. Not 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.