Release 4

Observation-example-1minute-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 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 with Details</b> </p> <p> <b> id</b> : 1minute-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> : 1 minute Apgar Score <span> (Details : {LOINC code '9272-6' = '1 minute Apgar Score', given as '1 minute Apgar Score'};
           {SNOMED CT code '169895004' = 'Apgar at 1 minute', given as 'Apgar at 1 minute'})</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> : 0 {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 '32406-1' = '1 minute Apgar Color', given as '1 minute Apgar Color'};
             {SNOMED CT code '249227004' = 'Apgar color score', given as 'Apgar color score'})</span> </p> <p> <b> value</b> : 0. The baby's whole body is completely bluish-gray or pale <span> (Details : {LOINC code 'LA6722-8' = 'The baby's whole body is completely bluish-gray or
             pale', given as 'The baby's whole body is completely bluish-gray or pale'}; {http://acme.ped/apgarco
            lor code '0' = '0)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span> (Details : {LOINC code '32407-9' = '1 minute Apgar Heart rate', given as '1 minute Apgar
             Heart Rate'}; {SNOMED CT code '249223000' = 'Apgar heart rate score', given as 'Apgar
             heart rate score'})</span> </p> <p> <b> value</b> : 0. No heart rate <span> (Details : {LOINC code 'LA6716-0' = 'No heart rate', given as 'No heart rate'}; {http://acme.ped/apg
            arheartrate code '0' = '0)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar response to stimulus score <span> (Details : {LOINC code '32409-5' = '1 minute Apgar Reflex irritability', given as '1 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> : 0. No response to airways being suctioned <span> (Details : {LOINC code 'LA6719-4' = 'No response to airways being suctioned', given as
             'No response to airways being suctioned'}; {http://acme.ped/apgarreflexirritability code
             '0' = '0)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar muscle tone score <span> (Details : {LOINC code '32408-7' = '1 minute Apgar Muscle tone', given as '1 minute Apgar
             Muscle Tone'}; {SNOMED CT code '249225007' = 'Apgar muscle tone score', given as 'Apgar
             muscle tone score'})</span> </p> <p> <b> value</b> : 0. Limp; no movement <span> (Details : {LOINC code 'LA6713-7' = 'Limp; no movement', given as 'Limp; no movement'};
             {http://acme.ped/apgarmuscletone code '0' = '0)</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Apgar respiratory effort score <span> (Details : {LOINC code '32410-3' = '1 minute Apgar Respiratory effort', given as '1 minute
             Apgar Respiratory effort'}; {SNOMED CT code '249224006' = 'Apgar respiratory effort score',
             given as 'Apgar respiratory effort score'})</span> </p> <p> <b> value</b> : 0. Not breathing <span> (Details : {LOINC code 'LA6725-1' = 'Not breathing', given as 'Not breathing'}; {http://acme.ped/apg
            arrespiratoryeffort code '0' = '0)</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.