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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 scores as related QuestionnaireAnswer
{ "resourceType": "Observation", "id": "gcs-qa", "text": { "status": "generated", "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><p><b>derivedFrom</b>: <a>GCS form results. Generated Summary: questionnaire: http://hl7.org/fhir/Questionnaire/gcs; status: completed; authored: 11 Dec. 2014, 3:44:16 pm</a></p></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" } } ], "derivedFrom": [ { "reference": "QuestionnaireResponse/gcs", "display": "GCS form results" } ] }
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.