This page is part of the FHIR Specification (v4.6.0: R5 Draft Ballot). 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 | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw XML (canonical form + also see XML Format Specification)
Example of a 1 minute Apgar score with individual score as components (id = "1minute-apgar-score")
<?xml version="1.0" encoding="UTF-8"?> <Observation xmlns="http://hl7.org/fhir"> <id value="1minute-apgar-score"/> <!-- Using a contained patient for the purposes of this example Observation. Typically the reference would be to an external resource --><text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative</b> </p> <p/> <p> <b> category</b> : <span> Survey</span> </p> <p> <b> code</b> : <span> 1 minute Apgar Score</span> </p> <p> <b> subject</b> : <a> </a> </p> <blockquote> <p> <b> identifier</b> : id: 12345</p> <p> <b> active</b> : true</p> <p> <b> name</b> : Peter James Chalmers </p> <p> <b> gender</b> : male</p> <p> <b> birthDate</b> : 2016-05-18</p> </blockquote> <p> <b> effective</b> : 19 May 2016, 8:33:22 am</p> <p> <b> performer</b> : <a> Generated Summary: id: 23; active; Adam Careful </a> </p> <p> <b> value</b> : 0 {score}</p> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : <span> Apgar color score</span> </p> <p> <b> value</b> : <span> 0. The baby's whole body is completely bluish-gray or pale</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : <span> Apgar respiratory effort score</span> </p> <p> <b> value</b> : <span> 0. No heart rate</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : <span> Apgar response to stimulus score</span> </p> <p> <b> value</b> : <span> 0. No response to airways being suctioned</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : <span> Apgar muscle tone score</span> </p> <p> <b> value</b> : <span> 0. Limp; no movement</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : <span> Apgar respiratory effort score</span> </p> <p> <b> value</b> : <span> 0. Not breathing</span> </p> </blockquote> </div> </text> <contained> <Patient> <id value="newborn"/> <!-- MRN assigned by ACME healthcare on --><identifier> <system value="http://acmehealthcare/org/mrns"/> <value value="12345"/> </identifier> <active value="true"/> <!-- Peter James Chalmers --><name> <family value="Chalmers"/> <given value="Peter"/> <given value="James"/> </name> <!-- use FHIR code system for male / female --><gender value="male"/> <birthDate value="2016-05-18"> <extension url="http://hl7.org/fhir/StructureDefinition/patient-birthTime"> <valueDateTime value="2016-05-18T10:28:45Z"/> </extension> </birthDate> </Patient> </contained> <status value="final"/> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/observation-category"/> <code value="survey"/> <display value="Survey"/> </coding> <text value="Survey"/> </category> <code> <coding> <system value="http://loinc.org"/> <code value="9272-6"/> <display value="1 minute Apgar Score"/> </coding> <coding> <system value="http://snomed.info/sct"/> <code value="169895004"/> <display value="Apgar at 1 minute"/> </coding> <text value="1 minute Apgar Score"/> </code> <subject> <reference value="#newborn"/> </subject> <effectiveDateTime value="2016-05-18T22:33:22Z"/> <performer> <reference value="Practitioner/example"/> </performer> <valueQuantity> <value value="0"/> <system value="http://unitsofmeasure.org"/> <code value="{score}"/> </valueQuantity> <component> <code> <coding> <system value="http://loinc.org"/> <code value="32406-1"/> <display value="1 minute Apgar Color"/> </coding> <coding> <system value="http://snomed.info/sct"/> <code value="249227004"/> <display value="Apgar color score"/> </coding> <text value="Apgar color score"/> </code> <valueCodeableConcept> <coding> <!-- this extension maps a numeric score to the code this may already be known and unecessary --><extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue"> <valueDecimal value="0"/> </extension> <system value="http://loinc.org"/> <code value="LA6722-8"/> <display value="The baby's whole body is completely bluish-gray or pale"/> </coding> <coding> <system value="http://acme.ped/apgarcolor"/> <code value="0"/> </coding> <text value="0. The baby's whole body is completely bluish-gray or pale"/> </valueCodeableConcept> </component> <component> <code> <coding> <system value="http://loinc.org"/> <code value="32407-9"/> <display value="1 minute Apgar Heart Rate"/> </coding> <coding> <system value="http://snomed.info/sct"/> <code value="249223000"/> <display value="Apgar heart rate score"/> </coding> <text value="Apgar respiratory effort score"/> </code> <valueCodeableConcept> <coding> <!-- this extension maps a numeric score to the code this may already be known and unecessary --><extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue"> <valueDecimal value="0"/> </extension> <system value="http://loinc.org"/> <code value="LA6716-0"/> <display value="No heart rate"/> </coding> <coding> <system value="http://acme.ped/apgarheartrate"/> <code value="0"/> </coding> <text value="0. No heart rate"/> </valueCodeableConcept> </component> <component> <code> <coding> <system value="http://loinc.org"/> <code value="32409-5"/> <display value="1 minute Apgar Reflex Irritability"/> </coding> <coding> <system value="http://snomed.info/sct"/> <code value="249226008"/> <display value="Apgar response to stimulus score"/> </coding> <text value="Apgar response to stimulus score"/> </code> <valueCodeableConcept> <coding> <!-- this extension maps a numeric score to the code this may already be known and unecessary --><extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue"> <valueDecimal value="0"/> </extension> <system value="http://loinc.org"/> <code value="LA6719-4"/> <display value="No response to airways being suctioned"/> </coding> <coding> <system value="http://acme.ped/apgarreflexirritability"/> <code value="0"/> </coding> <text value="0. No response to airways being suctioned"/> </valueCodeableConcept> </component> <component> <code> <coding> <system value="http://loinc.org"/> <code value="32408-7"/> <display value="1 minute Apgar Muscle Tone"/> </coding> <coding> <system value="http://snomed.info/sct"/> <code value="249225007"/> <display value="Apgar muscle tone score"/> </coding> <text value="Apgar muscle tone score"/> </code> <valueCodeableConcept> <coding> <!-- this extension maps a numeric score to the code this may already be known and unecessary --><extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue"> <valueDecimal value="0"/> </extension> <system value="http://loinc.org"/> <code value="LA6713-7"/> <display value="Limp; no movement"/> </coding> <coding> <system value="http://acme.ped/apgarmuscletone"/> <code value="0"/> </coding> <text value="0. Limp; no movement"/> </valueCodeableConcept> </component> <component> <code> <coding> <system value="http://loinc.org"/> <code value="32410-3"/> <display value="1 minute Apgar Respiratory effort"/> </coding> <coding> <system value="http://snomed.info/sct"/> <code value="249224006"/> <display value="Apgar respiratory effort score"/> </coding> <text value="Apgar respiratory effort score"/> </code> <valueCodeableConcept> <coding> <!-- this extension maps a numeric score to the code this may already be known and unecessary --><extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue"> <valueDecimal value="0"/> </extension> <system value="http://loinc.org"/> <code value="LA6725-1"/> <display value="Not breathing"/> </coding> <coding> <system value="http://acme.ped/apgarrespiratoryeffort"/> <code value="0"/> </coding> <text value="0. Not breathing"/> </valueCodeableConcept> </component> </Observation>
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.