Functional Assessment - Glasgow Coma

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 8/25/2022
  • SDWG: 3/9/2023

C-CDA 2.1 Example:

  • Functional Status Section 2.16.840.1.113883.10.20.22.2.14 and 2.16.840.1.113883.10.20.22.2.14:2014-06-09
  • Assessment Scale Observation 2.16.840.1.113883.10.20.22.4.69
  • Assessment Scale Observation 2.16.840.1.113883.10.20.22.4.69:2022-06-01
  • Assessment Scale Supporting Observation 2.16.840.1.113883.10.20.22.4.86
  • Assessment Scale Supporting Observation 2.16.840.1.113883.10.20.22.4.86:2022-06-01

Reference to full CDA sample:

  • None

Validation location

Comments

  • This is an example of a Glasgow Coma Scale. It illustrates an assessment in the Functional Status Section.

Custodian

  • Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)

Keywords

  • Glasgow Coma

 

Example: download example view on GitHub 

<section>
    <templateId root="2.16.840.1.113883.10.20.22.2.14"/>
    <templateId root="2.16.840.1.113883.10.20.22.2.14" extension="2014-06-09"/>
    <code code="47420-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Functional status assessment note"/>
    <title>FUNCTIONAL STATUS</title>
    <text>
        <table border="1" width="100%">
            <thead>
                <tr>
                    <th>Assessment</th>
                    <th>Effective Dates</th>
                    <th>Results of Evaluation</th>
                </tr>
            </thead>
            <tbody>
                <tr> 
                <!-- If desired you can include individual questions/answer here - see PHQ9 Example -->
                    <td ID="assessmentTotal">Glasgow coma scale</td>
                    <td>February 14,2012</td>
                    <td>9</td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry>
        <observation classCode="OBS" moodCode="EVN">
            <templateId root="2.16.840.1.113883.10.20.22.4.69"/>
            <templateId root="2.16.840.1.113883.10.20.22.4.69" extension="2022-06-01"/>
            <id root="4f6d8f2d-2efd-41c4-8ef1-465e00706948"/>
            <code code="35088-4" displayName="Glasgow coma scale"
                codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
            <statusCode code="completed"/>   
            <effectiveTime value="20120214"/>
            <!-- Summed score is also in an observation below -->
            <value xsi:type="INT" value="9"/>
            <entryRelationship typeCode="COMP">
                <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.86"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2022-06-01"/>
                    <id root="f4dce790-8328-11db-9fe1-0800200c9a44"/>
                    <code code="9267-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Glasgow coma score eye opening"/>             
                    <statusCode code="completed"/>
                    <value xsi:type="INT" value="3"/>
                    <!-- Systems may send a second value with LOINC answer concept  -->
                    <!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
                    <value xsi:type="CO" code="LA6555-2" displayName="Eye opening to verbal command"
                        codeSystem="2.16.840.1.113883.6.1"/>
                </observation>
            </entryRelationship>
            <entryRelationship typeCode="COMP">
                <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.86"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2022-06-01"/>
                    <id root="f4dce790-8328-11db-9fe1-0800200c9a44"/>
                    <code code="9268-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Glasgow coma score motor"/>               
                    <statusCode code="completed"/>
                    <value xsi:type="INT" value="3"/>
                    <!-- Systems may send a second value with LOINC answer concept  -->
                    <!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
                    <value xsi:type="CO" code="LA6564-4" displayName="Flexion to pain"
                        codeSystem="2.16.840.1.113883.6.1"/>
                </observation>
            </entryRelationship>
            <entryRelationship typeCode="COMP">
                <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.86"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2022-06-01"/>
                    <id root="f4dce790-8328-11db-9fe1-0800200c9a44"/>
                    <code code="9270-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Glasgow coma score verbal"/>
                     <statusCode code="completed"/>
                    <value xsi:type="INT" value="3"/>
                    <!-- Systems may send a second value with LOINC answer concept  -->
                    <!-- xsi:type could be CD or CO - CO Indicates to receiver that these values can be put in an ordered list -->
                    <value xsi:type="CO" code="LA6559-4" displayName="Inappropriate words"
                        codeSystem="2.16.840.1.113883.6.1"/>
                </observation>
            </entryRelationship>
            <entryRelationship typeCode="COMP">
                <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.86"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.86" extension="2022-06-01"/>
                    <id root="9daa31dd-2a72-40b8-a8e9-34c266935a15"/>
                    <code code="9269-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Glasgow coma score total"/>
                    <text>
                        <reference value="#assessmentTotal"/>
                    </text>
                    <statusCode code="completed"/>
                    <value xsi:type="INT" value="9"/>
                </observation>
            </entryRelationship>
        </observation>
    </entry>
</section>

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