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 example of a herd screening ELISA assay for Mycoplasmal Pneumonia in Pigs. (id = "herd1")
<?xml version="1.0" encoding="UTF-8"?> <Observation xmlns="http://hl7.org/fhir"> <id value="herd1"/> <!-- the mandatory status --> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative</b> </p> <p/> <p> <b> category</b> : <span> Laboratory</span> </p> <p> <b> code</b> : <span> Mycoplasma hyopneumoniae - MHP</span> </p> <p> <b> subject</b> : <a> Generated Summary: id: 20171120-1234; active; type: animal; actual; <span> Porcine</span> ; name: Breeding herd; 2500</a> </p> <p> <b> encounter</b> : <span> part of a health assurance program</span> </p> <p> <b> effective</b> : 2017-11-20</p> <p> <b> value</b> : 0.2 % (sample/positive control)</p> <p> <b> interpretation</b> : <span> Negative</span> </p> <p> <b> specimen</b> : <a> 30 serum. Generated Summary: id: 20171120-1234; <span> Pooled serum sample</span> ; Pooled serum sample from 30 individuals</a> </p> <h3> ReferenceRanges</h3> <table> <tr> <td> -</td> <td> <b> Text</b> </td> </tr> <tr> <td> *</td> <td> >0.4 Positive; 0.3 to 0.4 Suspect < 0.3 Negative</td> </tr> </table> </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="laboratory"/> <display value="Laboratory"/> </coding> <text value="Laboratory"/> </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="80219-9"/> <!-- more generic methodless LOINC --> <display value="Mycoplasma hyopneumoniae Ab sample/Positive control in Serum by Immunoassay"/> </coding> <!-- Also, a local code specific to the source system --> <coding> <system value="http://acme.org/devices/clinical-codes"/> <code value="Mycoplasma"/> <display value="Mycoplasma"/> </coding> <text value="Mycoplasma hyopneumoniae - MHP"/> </code> <!-- subject is a herd of 2500 breding sows --> <subject> <reference value="Group/herd1"/> </subject> <encounter> <display value="part of a health assurance program"/> </encounter> <effectiveDateTime value="2017-11-20"/> <!-- 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="0.2"/> <unit value="% (sample/positive control)"/> <system value="http://unitsofmeasure.org"/> <code value="%"/> </valueQuantity> <interpretation> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/> <code value="NEG"/> <display value="Negative"/> </coding> <text value="Negative"/> </interpretation> <!-- Specimen is a pooled serology sample of 30 animals. --> <specimen> <reference value="Specimen/pooled-serum"/> <display value="30 serum"/> </specimen> <referenceRange> <text value=">0.4 Positive; 0.3 to 0.4 Suspect < 0.3 Negative"/> </referenceRange> </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.