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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
{ "resourceType": "Observation", "id": "glasgow", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource "glasgow" </p></div><p><b>status</b>: final</p><p><b>code</b>: Glasgow Coma Scale , (GCS) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9269-2 "Glasgow coma score total")</span></p><p><b>subject</b>: <a href=\"patient-example.html\">Patient/example: Peter James Chalmers</a> "Peter CHALMERS"</p><p><b>effective</b>: 2014-12-11T04:44:16Z</p><p><b>value</b>: 13 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><blockquote><p><b>referenceRange</b></p><p><b>high</b>: 8 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Severe TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 9 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>high</b>: 12 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Moderate TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></p></blockquote><blockquote><p><b>referenceRange</b></p><p><b>low</b>: 13 {score}<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code {score} = '{score}')</span></p><p><b>type</b>: Mild TBI <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> ()</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: GCS Motor <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9268-4 "Glasgow coma score motor")</span></p><p><b>value</b>: 5 (Localizes painful stimuli) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#5 "Localizes painful stimuli"; <a href=\"https://loinc.org/\">LOINC</a>#LA6566-9 "Localizing pain")</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: GSC Verbal <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9270-0 "Glasgow coma score verbal")</span></p><p><b>value</b>: 4 (Confused, disoriented) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#4 "Confused, disoriented"; <a href=\"https://loinc.org/\">LOINC</a>#LA6560-2 "Confused")</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Eyes <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#9267-6 "Glasgow coma score eye opening")</span></p><p><b>value</b>: 4 (Opens eyes spontaneously) <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (codes#4 "Opens eyes spontaneously"; <a href=\"https://loinc.org/\">LOINC</a>#LA6556-0 "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/ordinalValue", "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/ordinalValue", "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/ordinalValue", "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.