This page is part of the FHIR Specification (v4.5.0: R5 Preview #3). 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: R5 R4B R4 R3 R2
Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw XML (canonical form + also see XML Format Specification)
Simple Weight Example (id = "example")
<?xml version="1.0" encoding="UTF-8"?> <Observation xmlns="http://hl7.org/fhir"> <id value="example"/> <!-- the mandatory quality flags: --> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative</b> </p> <p> <b> id</b> : example</p> <p/> <p> <b> category</b> : <span> Vital Signs</span> </p> <p> <b> code</b> : <span> Body Weight</span> </p> <p> <b> subject</b> : <a> Generated Summary: id: example; Medical record number: 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); -unknown-(HOME), ph: (03) 5555 6473(WORK), ph: (03) 3410 5613(MOBILE), ph: (03) 5555 8834(OLD); gender: male; birthDate: 1974-12-25; </a> </p> <p> <b> encounter</b> : <a> Generated Summary: id: example; status: in-progress; <span> inpatient encounter</span> </a> </p> <p> <b> effective</b> : 2016-03-28</p> <p> <b> value</b> : 185 lbs</p> </div> </text> <status value="final"/> <!-- category code is A code that classifies the general type of observation being made. This is used for searching, sorting and display purposes. --> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/observation-category"/> <code value="vital-signs"/> <display value="Vital Signs"/> </coding> </category> <!-- Observations are often coded in multiple code systems. - LOINC provides codes of varying granularity (though not usefully more specific in this particular case) and more generic LOINCs can be mapped to more specific codes as shown here - snomed provides a clinically relevant code that is usually less granular than LOINC - the source system provides its own code, which may be less or more granular than LOINC --> <code> <!-- LOINC - always recommended to have a LOINC code --> <coding> <system value="http://loinc.org"/> <code value="29463-7"/> <!-- more generic methodless LOINC --> <display value="Body Weight"/> </coding> <coding> <system value="http://loinc.org"/> <code value="3141-9"/> <!-- translation is more specific method = measured LOINC --> <display value="Body weight Measured"/> </coding> <!-- SNOMED CT Codes - becoming more common --> <coding> <system value="http://snomed.info/sct"/> <code value="27113001"/> <display value="Body weight"/> </coding> <!-- Also, a local code specific to the source system --> <coding> <system value="http://acme.org/devices/clinical-codes"/> <code value="body-weight"/> <display value="Body Weight"/> </coding> </code> <subject> <reference value="Patient/example"/> </subject> <encounter> <reference value="Encounter/example"/> </encounter> <effectiveDateTime value="2016-03-28"/> <!-- In FHIR, units may be represented twice. Once in the agreed human representation, and once in a coded form. Both is best, since it's not always possible to infer one from the other in code. When a computable unit is provided, UCUM (http://unitsofmeasure.org) is always preferred, but it doesn't provide notional units (such as "tablet"), etc. For these, something else is required (e.g. SNOMED CT) --> <valueQuantity> <value value="185"/> <unit value="lbs"/> <system value="http://unitsofmeasure.org"/> <code value="[lb_av]"/> </valueQuantity> </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.