This page is part of the FHIR Specification (v4.6.0: R5 Draft Ballot). 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
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)
An exam finding using pattern 3 described in the "Using Codes in Observation" Section (id = "abdo-tender")
<?xml version="1.0" encoding="UTF-8"?> <Observation xmlns="http://hl7.org/fhir"> <id value="abdo-tender"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative</b> </p> <p/> <p> <b> category</b> : <span> Exam</span> </p> <p> <b> code</b> : <span> Abdominal tenderness</span> </p> <p> <b> subject</b> : <a> Generated Summary: Medical record number: 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); , Phone: (03) 5555 6473, Phone: (03) 3410 5613, Phone: (03) 5555 8834; gender: male; birthDate: 1974-12-25; </a> </p> <p> <b> encounter</b> : <a> Generated Summary: status: in-progress; <span> inpatient encounter</span> </a> </p> <p> <b> effective</b> : 2 Apr. 2018, 7:30:10 pm --> (ongoing)</p> <p> <b> issued</b> : 4 Apr. 2018, 12:30:10 am</p> <p> <b> value</b> : true</p> <p> <b> interpretation</b> : <span> Abnormal</span> </p> </div> </text> <status value="final"/> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/observation-category"/> <code value="exam"/> <display value="Exam"/> </coding> </category> <code> <coding> <system value="http://snomed.info/sct"/> <code value="43478001"/> <display value="Abdominal tenderness (finding)"/> </coding> <text value="Abdominal tenderness"/> </code> <subject> <reference value="Patient/example"/> </subject> <encounter> <reference value="Encounter/example"/> </encounter> <effectivePeriod> <start value="2018-04-02T10:30:10+01:00"/> </effectivePeriod> <issued value="2018-04-03T15:30:10+01:00"/> <valueBoolean value="true"/> <interpretation> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/> <code value="A"/> <display value="Abnormal"/> </coding> <text value="Abnormal"/> </interpretation> </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.