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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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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</b></p><p/><p><b>code</b>: <span>Glasgow Coma Scale , (GCS)</span></p><p><b>subject</b>: <a>Peter James Chalmers. Generated Summary: Medical record number: 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); , Phone: (03) 5555 6473, Phone: (03) 3410 5613, Phone: (03) 5555 8834; gender: male; birthDate: 1974-12-25; </a></p><p><b>effective</b>: 11 Dec. 2014, 3:44:16 pm</p><p><b>value</b>: 13 {score}</p><blockquote><p><b>referenceRange</b></p><p><b>high</b>: 8 {score}</p><p><b>type</b>: <span>Severe TBI</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 9 {score}</p><p><b>high</b>: 12 {score}</p><p><b>type</b>: <span>Moderate TBI</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 13 {score}</p><p><b>type</b>: <span>Mild TBI</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span>GCS Motor</span></p><p><b>value</b>: <span>5 (Localizes painful stimuli)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span>GSC Verbal</span></p><p><b>value</b>: <span>4 (Confused, disoriented)</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span>Eyes</span></p><p><b>value</b>: <span>4 (Opens eyes 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/ordinalValue" ]; 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/ordinalValue" ]; 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/ordinalValue" ]; 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.