This page is part of the FHIR Specification (v3.3.0: R4 Ballot 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R4 R3
Orders and Observations Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Device, Encounter, Patient, Practitioner |
An example of a comprehensive bone marrow report (id = "report")
<Bundle xmlns="http://hl7.org/fhir"> <id value="report"/> <type value="collection"/> <entry> <fullUrl value="https://example.com/base/DiagnosticReport/report"/> <resource> <DiagnosticReport> <id value="report"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : report</p> <p> <b> status</b> : final</p> <p> <b> code</b> : comprehensive bone marrow report <span> (Details )</span> </p> <p> <b> subject</b> : <a> Everywoman, Eve A, MRN: 123456789</a> </p> <p> <b> effective</b> : 02/01/2015 1:20:10 PM</p> <p> <b> issued</b> : 06/01/2015 1:20:10 PM</p> <p> <b> performer</b> : <a> Molecular Diagnostic Laboratory</a> </p> <p> <b> specimen</b> : <a> Bone marrow ID: MLD45-Z4-1234</a> </p> <p> <b> result</b> : </p> <ul> <li> <a> Observation/o1</a> </li> <li> <a> Observation/o2</a> </li> <li> <a> Observation/o3</a> </li> <li> <a> Observation/o4</a> </li> <li> <a> Observation/o5</a> </li> <li> <a> Observation/o6</a> </li> <li> <a> Observation/o7</a> </li> <li> <a> Observation/o8</a> </li> <li> <a> Observation/o9</a> </li> <li> <a> Observation/o10</a> </li> <li> <a> Observation/o11</a> </li> <li> <a> Observation/o12</a> </li> <li> <a> Observation/o13</a> </li> </ul> </div> </text> <extension url="http://hl7.org/fhir/StructureDefinition/DiagnosticReport-geneticsAssessedCondition"> <valueReference> <reference value="Condition/c1"/> </valueReference> </extension> <status value="final"/> <code> <text value="comprehensive bone marrow report"/> </code> <subject> <reference value="Patient/genetics-example1"/> <display value="Everywoman, Eve A, MRN: 123456789"/> </subject> <effectiveDateTime value="2015-01-02T13:20:10+01:00"/> <issued value="2015-01-06T13:20:10+01:00"/> <performer> <reference value="Practitioner/genetics-example1"/> <display value="Molecular Diagnostic Laboratory"/> </performer> <specimen> <reference value="Specimen/genetics-example1"/> <display value="Bone marrow ID: MLD45-Z4-1234"/> </specimen> <result> <reference value="Observation/o1"/> </result> <result> <reference value="Observation/o2"/> </result> <result> <reference value="Observation/o3"/> </result> <result> <reference value="Observation/o4"/> </result> <result> <reference value="Observation/o5"/> </result> <result> <reference value="Observation/o6"/> </result> <result> <reference value="Observation/o7"/> </result> <result> <reference value="Observation/o8"/> </result> <result> <reference value="Observation/o9"/> </result> <result> <reference value="Observation/o10"/> </result> <result> <reference value="Observation/o11"/> </result> <result> <reference value="Observation/o12"/> </result> <result> <reference value="Observation/o13"/> </result> </DiagnosticReport> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o1"/> <resource> <Observation> <id value="o1"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o1</p> <p> <b> status</b> : final</p> <p> <b> code</b> : Leukocytes [#/volume] in Blood <span> (Details : {LOINC code '26464-8' = 'Leukocytes [#/volume] in Blood', given as 'Leukocytes [#/volume] in Blood'})</span> </p> <p> <b> value</b> : 31.9 K/ul</p> </div> </text> <status value="final"/> <code> <coding> <system value="http://loinc.org"/> <code value="26464-8"/> <display value="Leukocytes [#/volume] in Blood"/> </coding> </code> <valueQuantity> <value value="31.9"/> <unit value="K/ul"/> </valueQuantity> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o2"/> <resource> <Observation> <id value="o2"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o2</p> <p> <b> status</b> : final</p> <p> <b> code</b> : Hematocrit [Volume Fraction] of Blood <span> (Details : {LOINC code '20570-8' = 'Hematocrit [Volume Fraction] of Blood', given as 'Hematocrit [Volume Fraction] of Blood'})</span> </p> <p> <b> value</b> : 27 %</p> </div> </text> <status value="final"/> <code> <coding> <system value="http://loinc.org"/> <code value="20570-8"/> <display value="Hematocrit [Volume Fraction] of Blood"/> </coding> </code> <valueQuantity> <value value="27"/> <unit value="%"/> </valueQuantity> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o3"/> <resource> <Observation> <id value="o3"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o3</p> <p> <b> status</b> : final</p> <p> <b> code</b> : Platelets [#/volume] in Blood <span> (Details : {LOINC code '26515-7' = 'Platelets [#/volume] in Blood', given as 'Platelets [#/volume] in Blood'})</span> </p> <p> <b> value</b> : 84 K/ul</p> </div> </text> <status value="final"/> <code> <coding> <system value="http://loinc.org"/> <code value="26515-7"/> <display value="Platelets [#/volume] in Blood"/> </coding> </code> <valueQuantity> <value value="84"/> <unit value="K/ul"/> </valueQuantity> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o4"/> <resource> <Observation> <id value="o4"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o4</p> <p> <b> status</b> : final</p> <p> <b> code</b> : NPM1 gene mutations found [Identifier] in Bone marrow by Molecular genetics method Nominal <span> (Details : {LOINC code '75034-9' = 'NPM1 gene mutations found [Identifier] in Bone marrow by Molecular genetics method Nominal', given as 'NPM1 gene mutations found [Identifier] in Bone marrow by Molecular genetics method Nominal'})</span> </p> <p> <b> value</b> : Positive <span> (Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span> </p> </div> </text> <status value="final"/> <code> <coding> <system value="http://loinc.org"/> <code value="75034-9"/> <display value="NPM1 gene mutations found [Identifier] in Bone marrow by Molecular genetics method Nominal"/> </coding> </code> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct"/> <code value="10828004"/> <display value="Positive"/> </coding> </valueCodeableConcept> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o5"/> <resource> <Observation> <id value="o5"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o5</p> <p> <b> status</b> : final</p> <p> <b> code</b> : FLT3 gene mutation analysis in Bone marrow by Molecular genetics method Narrative <span> (Details : {LOINC code '54447-8' = 'FLT3 gene mutation analysis in Bone marrow by Molecular genetics method Narrative', given as 'FLT3 gene mutation analysis in Bone marrow by Molecular genetics method Narrative'})</span> </p> <p> <b> value</b> : Negative <span> (Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span> </p> </div> </text> <status value="final"/> <code> <coding> <system value="http://loinc.org"/> <code value="54447-8"/> <display value="FLT3 gene mutation analysis in Bone marrow by Molecular genetics method Narrative"/> </coding> </code> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct"/> <code value="260385009"/> <display value="Negative"/> </coding> </valueCodeableConcept> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o6"/> <resource> <Observation> <id value="o6"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o6</p> <p> <b> status</b> : final</p> <p> <b> code</b> : KIT gene mutation analysis in Bone marrow by Molecular genetics method Narrative <span> (Details : {LOINC code '55201-8' = 'KIT gene mutation analysis in Blood or Tissue by Molecular genetics method Narrative', given as 'KIT gene mutation analysis in Bone marrow by Molecular genetics method Narrative'})</span> </p> <p> <b> value</b> : Negative <span> (Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span> </p> </div> </text> <status value="final"/> <code> <coding> <system value="http://loinc.org"/> <code value="55201-8"/> <display value="KIT gene mutation analysis in Bone marrow by Molecular genetics method Narrative"/> </coding> </code> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct"/> <code value="260385009"/> <display value="Negative"/> </coding> </valueCodeableConcept> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o7"/> <resource> <Observation> <id value="o7"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o7</p> <p> <b> status</b> : final</p> <p> <b> code</b> : Myeloblasts [#/volume] in Blood <span> (Details : {LOINC code '30444-4' = 'Myeloblasts [#/volume] in Blood', given as 'Myeloblasts [#/volume] in Blood'})</span> </p> <p> <b> value</b> : Positive <span> (Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span> </p> </div> </text> <status value="final"/> <code> <coding> <system value="http://loinc.org"/> <code value="30444-4"/> <display value="Myeloblasts [#/volume] in Blood"/> </coding> </code> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct"/> <code value="10828004"/> <display value="Positive"/> </coding> </valueCodeableConcept> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o8"/> <resource> <Observation> <id value="o8"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o8</p> <p> <b> status</b> : final</p> <p> <b> code</b> : CD4 Ag [Presence] in Tissue by Immune stain <span> (Details : {LOINC code '47016-1' = 'CD4 Ag [Presence] in Tissue by Immune stain', given as 'CD4 Ag [Presence] in Tissue by Immune stain'})</span> </p> <p> <b> value</b> : Positive <span> (Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span> </p> </div> </text> <status value="final"/> <code> <coding> <system value="http://loinc.org"/> <code value="47016-1"/> <display value="CD4 Ag [Presence] in Tissue by Immune stain"/> </coding> </code> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct"/> <code value="10828004"/> <display value="Positive"/> </coding> </valueCodeableConcept> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o9"/> <resource> <Observation> <id value="o9"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o9</p> <p> <b> status</b> : final</p> <p> <b> code</b> : CD13 Ag [Presence] in Tissue by Immune stain <span> (Details : {LOINC code '49464-1' = 'CD13 Ag [Presence] in Tissue by Immune stain', given as 'CD13 Ag [Presence] in Tissue by Immune stain'})</span> </p> <p> <b> value</b> : Positive <span> (Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span> </p> </div> </text> <status value="final"/> <code> <coding> <system value="http://loinc.org"/> <code value="49464-1"/> <display value="CD13 Ag [Presence] in Tissue by Immune stain"/> </coding> </code> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct"/> <code value="10828004"/> <display value="Positive"/> </coding> </valueCodeableConcept> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o10"/> <resource> <Observation> <id value="o10"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o10</p> <p> <b> status</b> : final</p> <p> <b> code</b> : CD2 Ag [Presence] in Tissue by Immune stain <span> (Details : {LOINC code '49466-6' = 'CD2 Ag [Presence] in Tissue by Immune stain', given as 'CD2 Ag [Presence] in Tissue by Immune stain'})</span> </p> <p> <b> value</b> : Negative <span> (Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span> </p> </div> </text> <status value="final"/> <code> <coding> <system value="http://loinc.org"/> <code value="49466-6"/> <display value="CD2 Ag [Presence] in Tissue by Immune stain"/> </coding> </code> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct"/> <code value="260385009"/> <display value="Negative"/> </coding> </valueCodeableConcept> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o11"/> <resource> <Observation> <id value="o11"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o11</p> <p> <b> status</b> : final</p> <p> <b> code</b> : Karyotype [Identifier] in Bone marrow Nominal <span> (Details : {LOINC code '33893-9' = 'Karyotype [Identifier] in Bone marrow Nominal', given as 'Karyotype [Identifier] in Bone marrow Nominal'})</span> </p> <p> <b> value</b> : 46,XX[20] <span> (Details )</span> </p> </div> </text> <status value="final"/> <code> <coding> <system value="http://loinc.org"/> <code value="33893-9"/> <display value="Karyotype [Identifier] in Bone marrow Nominal"/> </coding> </code> <valueCodeableConcept> <text value="46,XX[20]"/> </valueCodeableConcept> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o12"/> <resource> <Observation> <id value="o12"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o12</p> <p> <b> status</b> : final</p> <p> <b> code</b> : MDS-associated genetic abnormalities <span> (Details )</span> </p> <p> <b> value</b> : Negative <span> (Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span> </p> </div> </text> <status value="final"/> <code> <text value="MDS-associated genetic abnormalities"/> </code> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct"/> <code value="260385009"/> <display value="Negative"/> </coding> </valueCodeableConcept> </Observation> </resource> </entry> <entry> <fullUrl value="https://example.com/base/Observation/o13"/> <resource> <Observation> <id value="o13"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : o13</p> <p> <b> status</b> : final</p> <p> <b> code</b> : AML-associated genetic abnormalities <span> (Details )</span> </p> <p> <b> value</b> : Negative <span> (Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span> </p> </div> </text> <status value="final"/> <code> <text value="AML-associated genetic abnormalities"/> </code> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct"/> <code value="260385009"/> <display value="Negative"/> </coding> </valueCodeableConcept> </Observation> </resource> </entry> </Bundle>
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.