Glasgow Coma Scale

Hinweis Standard Level: Draft!
Der nachfolgende Abschnitt des Implementierungsleitfadens wird als nicht vollständig genug oder nicht ausreichend geprüft angesehen, um ausschließen zu können, dass zukünftige Versionen rückwärtskompatibel bleiben. Im Anschluss an eine Ballotierung wird der Status in der Regel auf "Trial-Use" angehoben. Wir bitten hierzu um Meinungen und Vorschläge aus der Community.

Name: VitalSignDE_GCS (Simplifier Projekt Link)

Canonical: http://fhir.de/StructureDefinition/observation-de-vitalsign-gcs

identifierΣ0..*Identifier
basedOnΣ I0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)
partOfΣ I0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)
statusΣ ?!1..1codeBinding
vs-cat1..1CodeableConceptBinding
loincΣ1..1Coding
textΣ0..1string
subjectΣ I1..1Reference(Patient | Group)
focusΣ I0..*Reference(Resource)
encounterΣ I0..1Reference(Encounter)
effectivePeriodPeriod
effectiveTimingTiming
effectiveInstantinstant
effectiveDateTimeΣ I0..1dateTime
issuedΣ0..1instant
performerΣ I0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson)
valueΣ1..1decimal
comparatorΣ ?!0..1codeBinding
unitΣ1..1string
systemΣ I1..1uri
codeΣ1..1code
dataAbsentReasonI0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
note0..*Annotation
bodySite0..0CodeableConcept
method0..1CodeableConcept
specimenI0..0Reference(Specimen)
deviceI0..1Reference(Device | DeviceMetric)
lowI0..1SimpleQuantity
highI0..1SimpleQuantity
type0..1CodeableConceptBinding
appliesTo0..*CodeableConcept
ageI0..1Range
text0..1string
hasMemberΣ I0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)
derivedFromΣ I0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)
codeΣ1..1CodeableConcept
valueCodeableConceptCodeableConcept
valueStringstring
valueBooleanboolean
valueIntegerinteger
valueRangeRange
valueRatioRatio
valueSampledDataSampledData
valueTimetime
valueDateTimedateTime
valuePeriodPeriod
valueΣ1..1decimal
comparatorΣ ?!0..1codeBinding
unitΣ1..1string
systemΣ I1..1uri
codeΣ1..1code
dataAbsentReasonI0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
referenceRange0..*see (referenceRange)
loincΣ1..1Coding
textΣ0..1string
valueΣ1..1decimal
comparatorΣ ?!0..1codeBinding
unitΣ1..1string
systemΣ I1..1uri
codeΣ1..1code
dataAbsentReasonI0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
referenceRange0..*see (referenceRange)
loincΣ1..1Coding
textΣ0..1string
valueΣ1..1decimal
comparatorΣ ?!0..1codeBinding
unitΣ1..1string
systemΣ I1..1uri
codeΣ1..1code
dataAbsentReasonI0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
referenceRange0..*see (referenceRange)
loincΣ1..1Coding
textΣ0..1string
valueΣ1..1decimal
comparatorΣ ?!0..1codeBinding
unitΣ1..1string
systemΣ I1..1uri
codeΣ1..1code
dataAbsentReasonI0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
referenceRange0..*see (referenceRange)

{
    "resourceType": "Observation",
    "id": "Example-observation-gcs",
    "meta": {
        "profile":  [
            "http://fhir.de/StructureDefinition/observation-de-vitalsign-gcs"
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://terminology.hl7.org/CodeSystem/observation-category",
                    "code": "vital-signs"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "9269-2",
                "system": "http://loinc.org",
                "display": "Glasgow coma score total"
            }
        ]
    },
    "component":  [
        {
            "code": {
                "coding":  [
                    {
                        "code": "9270-0",
                        "system": "http://loinc.org",
                        "display": "Glasgow coma score verbal"
                    }
                ]
            },
            "valueQuantity": {
                "system": "http://unitsofmeasure.org",
                "value": 4,
                "code": "1",
                "unit": "Punktwert"
            }
        },
        {
            "code": {
                "coding":  [
                    {
                        "code": "9268-4",
                        "system": "http://loinc.org",
                        "display": "Glasgow coma score motor"
                    }
                ]
            },
            "valueQuantity": {
                "system": "http://unitsofmeasure.org",
                "value": 4,
                "code": "1",
                "unit": "Punktwert"
            }
        },
        {
            "code": {
                "coding":  [
                    {
                        "code": "9267-6",
                        "system": "http://loinc.org",
                        "display": "Glasgow coma score eye opening"
                    }
                ]
            },
            "valueQuantity": {
                "system": "http://unitsofmeasure.org",
                "value": 3,
                "code": "1",
                "unit": "Punktwert"
            }
        }
    ],
    "valueQuantity": {
        "system": "http://unitsofmeasure.org",
        "value": 11,
        "code": "1",
        "unit": "Punktwert"
    },
    "status": "final",
    "subject": {
        "reference": "https://server/Patient/example"
    },
    "effectiveDateTime": "2020-10-11"
}