Release 4

Observation-example-10minute-apgar-score.xml

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

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Example of a 10 minute Apgar score with individual score as components (id = "10minute-apgar-score")

<?xml version="1.0" encoding="UTF-8"?>

<Observation xmlns="http://hl7.org/fhir">
  <id value="10minute-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 with Details</b> </p> <p> <b> id</b> : 10minute-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> : 10 minute Apgar Score <span> (Details : {LOINC code '9271-8' = '10 minute Apgar Score', given as '10 minute Apgar Score'};
           {SNOMED CT code '169922007' = 'Apgar at 10 minutes', given as 'Apgar at 10 minutes'})</span> </p> <p> <b> subject</b> : id: newborn; 12345; active; Peter James Chalmers ; gender: male; birthDate: May 18,
         2016</p> <p> <b> effective</b> : May 18, 2016 10:33:22 PM</p> <p> <b> performer</b> : <a> Practitioner/example</a> </p> <p> <b> value</b> : 10 {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 '32401-2' = '10 minute Apgar Color', given as '10 minute Apgar
             Color'}; {SNOMED CT code '249227004' = 'Apgar color score', given as 'Apgar color score'})</span> </p> <p> <b> value</b> : 2. Good color all over <span> (Details : {LOINC code 'LA6724-4' = 'Good color all over', given as 'Good color all over'};
             {http://acme.ped/apgarcolor code '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span> (Details : {LOINC code '32402-0' = '10 minute Apgar Heart rate', given as '10 minute Apgar
             Heart Rate'}; {SNOMED CT code '249223000' = 'Apgar heart rate score', given as 'Apgar
             heart rate score'})</span> </p> <p> <b> value</b> : 2. At least 100 beats per minute <span> (Details : {LOINC code 'LA6718-6' = 'At least 100 beats per minute', given as 'At least
             100 beats per minute'}; {http://acme.ped/apgarheartrate code '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar response to stimulus score <span> (Details : {LOINC code '32404-6' = '10 minute Apgar Reflex irritability', given as '10
             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> : 2. Grimace and pulling away, cough, or sneeze during suctioning <span> (Details : {LOINC code 'LA6721-0' = 'Grimace and pulling away, cough, or sneeze during
             suctioning', given as 'Grimace and pulling away, cough, or sneeze during suctioning'};
             {http://acme.ped/apgarreflexirritability code '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar muscle tone score <span> (Details : {LOINC code '32403-8' = '10 minute Apgar Muscle tone', given as '10 minute
             Apgar Muscle Tone'}; {SNOMED CT code '249225007' = 'Apgar muscle tone score', given as
             'Apgar muscle tone score'})</span> </p> <p> <b> value</b> : 2. Active motion <span> (Details : {LOINC code 'LA6715-2' = 'Active motion', given as 'Active motion '}; {http://acme.ped/ap
            garmuscletone code '2' = '2)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span> (Details : {LOINC code '32405-3' = '10 minute Apgar Respiratory effort', given as '10
             minute Apgar Respiratory effort'}; {SNOMED CT code '249224006' = 'Apgar respiratory effort
             score', given as 'Apgar respiratory effort score'})</span> </p> <p> <b> value</b> : 2. Good, strong cry; normal rate and effort of breathing <span> (Details : {LOINC code 'LA6727-7' = 'Good, strong cry; normal rate and effort of breathing',
             given as 'Good, strong cry; normal rate and effort of breathing    '}; {http://acme.ped/apgarrespira
            toryeffort code '2' = '2)</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="9271-8"/> 
      <display value="10 minute Apgar Score"/> 
    </coding> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="169922007"/> 
      <display value="Apgar at 10 minutes"/> 
    </coding> 
    <text value="10 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="10"/> 
    <system value="http://unitsofmeasure.org"/> 
    <code value="{score}"/> 
  </valueQuantity> 
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="32401-2"/> 
        <display value="10 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="2"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6724-4"/> 
        <display value="Good color all over"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarcolor"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. Good color all over"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="32402-0"/> 
        <display value="10 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="2"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6718-6"/> 
        <display value="At least 100 beats per minute"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarheartrate"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. At least 100 beats per minute"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="32404-6"/> 
        <display value="10 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="2"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6721-0"/> 
        <display value="Grimace and pulling away, cough, or sneeze during suctioning"/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarreflexirritability"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. Grimace and pulling away, cough, or sneeze during suctioning"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="32403-8"/> 
        <display value="10 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="2"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6715-2"/> 
        <display value="Active motion "/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarmuscletone"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. Active motion"/> 
    </valueCodeableConcept> 
  </component> 
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="32405-3"/> 
        <display value="10 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="2"/> 
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6727-7"/> 
        <display value="Good, strong cry; normal rate and effort of breathing    "/> 
      </coding> 
      <coding> 
        <system value="http://acme.ped/apgarrespiratoryeffort"/> 
        <code value="2"/> 
      </coding> 
      <text value="2. Good, strong cry; normal rate and effort of 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.