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Observation-example-glasgow.xml

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

Raw XML (каноническая форма + also see XML Format Specification)

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Clinical assessment tool example - GCS with individual score as components (id = "glasgow")

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

<Observation xmlns="http://hl7.org/fhir">
  <id value="glasgow"/> 

  <!--     the mandatory quality flags:     -->
  <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : glasgow</p> <p> <b> status</b> : final</p> <p> <b> code</b> : Glasgow Coma Scale , (GCS) <span> (Details : {LOINC code '9269-2' = 'Glasgow coma score total', given as 'Glasgow coma score
           total'})</span> </p> <p> <b> subject</b> : <a> Peter James Chalmers</a> </p> <p> <b> effective</b> : Dec 11, 2014 4:44:16 AM</p> <p> <b> value</b> : 13 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <blockquote> <p> <b> referenceRange</b> </p> <p> <b> high</b> : 8 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> type</b> : Severe TBI <span> (Details )</span> </p> </blockquote> <blockquote> <p> <b> referenceRange</b> </p> <p> <b> low</b> : 9 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> high</b> : 12 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> type</b> : Moderate TBI <span> (Details )</span> </p> </blockquote> <blockquote> <p> <b> referenceRange</b> </p> <p> <b> low</b> : 13 {score}<span>  (Details: UCUM code {score} = '{score}')</span> </p> <p> <b> type</b> : Mild TBI <span> (Details )</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : GCS Motor <span> (Details : {LOINC code '9268-4' = 'Glasgow coma score motor', given as 'Glasgow coma score
             motor'})</span> </p> <p> <b> value</b> : 5 (Localizes painful stimuli) <span> (Details : {http:/acme.ec/codes code '5' = '5', given as 'Localizes painful stimuli'};
             {LOINC code 'LA6566-9' = 'Localizing pain', given as 'Localizing pain'})</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : GSC Verbal <span> (Details : {LOINC code '9270-0' = 'Glasgow coma score verbal', given as 'Glasgow coma
             score verbal'})</span> </p> <p> <b> value</b> : 4 (Confused, disoriented) <span> (Details : {http:/acme.ec/codes code '4' = '4', given as 'Confused, disoriented'}; {LOINC
             code 'LA6560-2' = 'Confused', given as 'Confused'})</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Eyes <span> (Details : {LOINC code '9267-6' = 'Glasgow coma score eye opening', given as 'Glasgow
             coma score eye opening'})</span> </p> <p> <b> value</b> : 4 (Opens eyes spontaneously) <span> (Details : {http:/acme.ec/codes code '4' = '4', given as 'Opens eyes spontaneously'};
             {LOINC code 'LA6556-0' = 'Eyes open spontaneously', given as 'Eyes open spontaneously'})</span> </p> </blockquote> </div> </text> <status value="final"/> 
  <!--    
    Observations are often coded in multiple code systems.
      - LOINC
    - or SNOMED
      -and/or the source system may provides its own "local" code, which may be less or
   more granular than LOINC.
  In this example there is only LOINC
      -->
  <code> 
    <!--     LOINC - always recommended to have a LOINC code     -->
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="9269-2"/> 
      <display value="Glasgow coma score total"/> 
    </coding> 
    <text value="Glasgow Coma Scale , (GCS)"/> 
  </code> 
  <subject> 
    <reference value="Patient/example"/> 
    <display value="Peter James Chalmers"/> 
  </subject> 
  <effectiveDateTime value="2014-12-11T04:44:16Z"/> 
  <!--     In FHIR, units may be represented twice. Once in the
    agreed human representation, and once in a coded form.
    In this example the UCUM unit is provided but no human representation since this is
   often not displayed
       -->
  <valueQuantity> 
    <value value="13"/> 
    <system value="http://unitsofmeasure.org"/> 
    <code value="{score}"/> 
  </valueQuantity> 
  <referenceRange> 
    <high> 
      <value value="8"/> 
      <system value="http://unitsofmeasure.org"/> 
      <code value="{score}"/> 
    </high> 
    <!--     meaning as text     -->
    <type> 
      <text value="Severe TBI"/> 
    </type> 
  </referenceRange> 
  <referenceRange> 
    <low> 
      <value value="9"/> 
      <system value="http://unitsofmeasure.org"/> 
      <code value="{score}"/> 
    </low> 
    <high> 
      <value value="12"/> 
      <system value="http://unitsofmeasure.org"/> 
      <code value="{score}"/> 
    </high> 
    <!--     meaning as text     -->
    <type> 
      <text value="Moderate TBI"/> 
    </type> 
  </referenceRange> 
  <referenceRange> 
    <low> 
      <value value="13"/> 
      <system value="http://unitsofmeasure.org"/> 
      <code value="{score}"/> 
    </low> 
    <!--     meaning as text     -->
    <type> 
      <text value="Mild TBI"/> 
    </type> 
  </referenceRange> 

  <!--    Using components since these measurements are typically reported and interpreted together
      -->
    <!--    GCS motor Component    -->
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="9268-4"/> 
        <display value="Glasgow coma score motor"/> 
      </coding> 
      <text value="GCS Motor"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
        <system value="http:/acme.ec/codes"/> 
        <code value="5"/> 
        <display value="Localizes painful stimuli"/> 
      </coding> 
      <coding> 
        <!--      This example has the extension which maps a numeric score to the code this may already
         be known and unecessary in the Observation resource     -->
        <extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue">
          <!--     from Element: extension     -->
          <valueDecimal value="5"/> 
          <!--     0..1 Value of extension     -->
        </extension> 
        <system value="http://loinc.org"/> 
        <code value="LA6566-9"/> 
        <display value="Localizing pain"/> 
      </coding> 
      <text value="5 (Localizes painful stimuli)"/> 
    </valueCodeableConcept> 
  </component> 
    <!--    GCS verbal Component    -->
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="9270-0"/> 
        <display value="Glasgow coma score verbal"/> 
      </coding> 
      <text value="GSC Verbal"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
        <system value="http:/acme.ec/codes"/> 
        <code value="4"/> 
        <display value="Confused, disoriented"/> 
      </coding> 
      <coding> 
        <!--      This example has the extension which maps a numeric score to the code this may already
         be known and unecessary in the Observation resource     -->
        <extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue">
          <!--     from Element: extension     -->
          <valueDecimal value="4"/> 
          <!--     0..1 Value of extension     -->
        </extension> 
        <system value="http://loinc.org"/> 
        <!--    technicallly the code is '5' and the LA is the identifier to do hav e both  would require
         an extention    -->
        <code value="LA6560-2"/> 
        <display value="Confused"/> 
      </coding> 
      <text value="4 (Confused, disoriented)"/> 
    </valueCodeableConcept> 
  </component> 
  <!--    GCS eyes Component    -->
  <component> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="9267-6"/> 
        <display value="Glasgow coma score eye opening"/> 
      </coding> 
      <text value="Eyes"/> 
    </code> 
    <valueCodeableConcept> 
      <coding> 
        <system value="http:/acme.ec/codes"/> 
        <code value="4"/> 
        <display value="Opens eyes spontaneously"/> 
      </coding> 
      <coding> 
        <!--      This example has the extension which maps a numeric score to the code this may already
         be known and unecessary in the Observation resource     -->
        <extension url="http://hl7.org/fhir/StructureDefinition/ordinalValue">
          <!--     from Element: extension     -->
          <valueDecimal value="4"/> 
          <!--     0..1 Value of extension     -->
        </extension> 
        <system value="http://loinc.org"/> 
        <!--    technicallly the code is '4' and the LA is the identifier to do hav e both  would require
         an extention    -->
        <code value="LA6556-0"/> 
        <display value="Eyes open spontaneously"/> 
      </coding> 
      <text value="4 (Opens eyes spontaneously)"/> 
    </valueCodeableConcept> 
  </component> 
</Observation> 

Примечание к использованию: мы очень стараемся приводить корректные и полезные примеры, но нормативно они не являются частью спецификации.