This page is part of the FHIR Specification (v5.0.0-ballot: FHIR R5 Ballot Preview). 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
Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner |
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Real-world patient example
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <http://loinc.org/rdf#> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix sct: <http://snomed.info/id/> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- [a fhir:Bundle; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "f001"]; fhir:Bundle.type [ fhir:value "collection"]; fhir:Bundle.entry [ fhir:index 0; fhir:Bundle.entry.fullUrl [ fhir:value "https://example.com/base/DiagnosticReport/f001" ]; fhir:Bundle.entry.resource <https://example.com/base/DiagnosticReport/f001> ], [ fhir:index 1; fhir:Bundle.entry.fullUrl [ fhir:value "https://example.com/base/ServiceRequest/req" ]; fhir:Bundle.entry.resource <https://example.com/base/ServiceRequest/req> ]] . <https://example.com/base/DiagnosticReport/f001> a fhir:DiagnosticReport; fhir:Resource.id [ fhir:value "f001"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h2><span title=\"Codes: {http://loinc.org 58410-2}\">Complete blood count (hemogram) panel - Blood by Automated count</span> (<span title=\"Codes: {http://snomed.info/sct 252275004}, {http://terminology.hl7.org/CodeSystem/v2-0074 HM}\">Haematology test</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td><b>Pieter van de Heuvel </b> male, DoB: 1944-11-17 ( id: 738472983 (USUAL))</td></tr><tr><td>Reported</td><td>2013-05-15T19:32:52+01:00</td></tr><tr><td>Identifier:</td><td> id: nr1239044 (OFFICIAL)</td></tr></table><p><b>Report Details</b></p><table class=\"grid\"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Reference Range</b></td><td><b>Flags</b></td><td><b>When For</b></td><td><b>Reported</b></td></tr><tr><td><a href=\"observation-example-f001-glucose.html\"><span title=\"Codes: {http://loinc.org 15074-8}\">Glucose [Moles/volume] in Blood</span></a></td><td>6.3 mmol/l</td><td>3.1 mmol/l - 6.2 mmol/l</td><td><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></td><td>2013-04-02T09:30:10+01:00</td><td>2013-04-03T15:30:10+01:00</td></tr><tr><td><a href=\"observation-example-f002-excess.html\"><span title=\"Codes: {http://loinc.org 11555-0}\">Base excess in Blood by calculation</span></a></td><td>12.6 mmol/l</td><td>7.1 mmol/l - 11.2 mmol/l</td><td><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></td><td>2013-04-02T10:30:10+01:00</td><td>2013-04-03T15:30:10+01:00</td></tr><tr><td><a href=\"observation-example-f003-co2.html\"><span title=\"Codes: {http://loinc.org 11557-6}\">Carbon dioxide in blood</span></a></td><td>6.2 kPa</td><td>4.8 kPa - 6.0 kPa</td><td><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></td><td>2013-04-02T10:30:10+01:00</td><td>2013-04-03T15:30:10+01:00</td></tr><tr><td><a href=\"observation-example-f004-erythrocyte.html\"><span title=\"Codes: {http://loinc.org 789-8}\">Erythrocytes [#/volume] in Blood by Automated count</span></a></td><td>4.12 10^12/L</td><td> 12-14 y Male: 4.4 - 5.2 x 10^12/L ; 12-14 y Female: 4.2 - 4.8 x 10^12/L ; 15-17 y Male: 4.6 - 5.4 x 10^12/L ; 15-17 y Female: 4.2 - 4.8 x 10^12/L ; 18-64 y Male: 4.6 - 5.4 x 10^12/L ; 18-64 y Female: 4.0 - 4.8 x 10^12/L ; 65-74 y Male: 4.3 - 5.3 x 10^12/L ; 65-74 y Female: 4.1 - 4.9 x 10^12/L </td><td><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation L}\">Low</span></td><td>2013-04-02T10:30:10+01:00</td><td>2013-04-03T15:30:10+01:00</td></tr><tr><td><a href=\"observation-example-f005-hemoglobin.html\"><span title=\"Codes: {http://loinc.org 718-7}\">Hemoglobin [Mass/volume] in Blood</span></a></td><td>7.2 g/dl</td><td>7.5 g/dl - 10 g/dl</td><td><span title=\"Codes: {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation L}\">Low</span></td><td>2013-04-05T10:30:10+01:00</td><td>2013-04-05T15:30:10+01:00</td></tr></table><p>Core lab</p></div>" ]; fhir:DiagnosticReport.identifier [ fhir:index 0; fhir:Identifier.use [ fhir:value "official" ]; fhir:Identifier.system [ fhir:value "http://www.bmc.nl/zorgportal/identifiers/reports" ]; fhir:Identifier.value [ fhir:value "nr1239044" ] ]; fhir:DiagnosticReport.basedOn [ fhir:index 0; fhir:Reference.reference [ fhir:value "ServiceRequest/req" ] ]; fhir:DiagnosticReport.status [ fhir:value "final"]; fhir:DiagnosticReport.category [ fhir:index 0; fhir:CodeableConcept.coding [ fhir:index 0; a sct:252275004; fhir:Coding.system [ fhir:value "http://snomed.info/sct" ]; fhir:Coding.code [ fhir:value "252275004" ]; fhir:Coding.display [ fhir:value "Haematology test" ] ], [ fhir:index 1; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0074" ]; fhir:Coding.code [ fhir:value "HM" ] ] ]; fhir:DiagnosticReport.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:58410-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "58410-2" ]; fhir:Coding.display [ fhir:value "Complete blood count (hemogram) panel - Blood by Automated count" ] ] ]; fhir:DiagnosticReport.subject [ fhir:Reference.reference [ fhir:value "Patient/f001" ]; fhir:Reference.display [ fhir:value "P. van den Heuvel" ] ]; fhir:DiagnosticReport.issued [ fhir:value "2013-05-15T19:32:52+01:00"^^xsd:dateTime]; fhir:DiagnosticReport.performer [ fhir:index 0; fhir:Reference.reference [ fhir:value "Organization/f001" ]; fhir:Reference.display [ fhir:value "Burgers University Medical Centre" ] ]; fhir:DiagnosticReport.result [ fhir:index 0; fhir:Reference.reference [ fhir:value "Observation/f001" ] ], [ fhir:index 1; fhir:Reference.reference [ fhir:value "Observation/f002" ] ], [ fhir:index 2; fhir:Reference.reference [ fhir:value "Observation/f003" ] ], [ fhir:index 3; fhir:Reference.reference [ fhir:value "Observation/f004" ] ], [ fhir:index 4; fhir:Reference.reference [ fhir:value "Observation/f005" ] ]; fhir:DiagnosticReport.conclusion [ fhir:value "Core lab"] . <https://example.com/base/ServiceRequest/req> a fhir:ServiceRequest; fhir:Resource.id [ fhir:value "req"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative: ServiceRequest</b><a name=\"req\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource ServiceRequest "req" </p></div><p><b>identifier</b>: id: L2381</p><p><b>status</b>: active</p><p><b>intent</b>: original-order</p><h3>Codes</h3><table class=\"grid\"><tr><td>-</td><td><b>Concept</b></td></tr><tr><td>*</td><td>Complete blood count (hemogram) panel - Blood by Automated count <span style=\"background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki\"> (<a href=\"https://loinc.org/\">LOINC</a>#58410-2)</span></td></tr></table><p><b>subject</b>: <a href=\"patient-example-f001-pieter.html\">Patient/f001: P. van den Heuvel</a> "Pieter VAN DE HEUVEL"</p><p><b>encounter</b>: <a href=\"encounter-example-f001-heart.html\">Encounter/f001</a></p><p><b>requester</b>: <a href=\"practitioner-example-f001-evdb.html\">Practitioner/f001: E.van den Broek</a> "Eric VAN DEN BROEK"</p><p><b>note</b>: patient almost fainted during procedure</p></div>" ]; fhir:DomainResource.extension [ fhir:index 0; fhir:Extension.url [ fhir:value "http://example.org/bodysitecode" ]; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; a sct:14975008; fhir:Coding.system [ fhir:value "http://snomed.info/sct" ]; fhir:Coding.code [ fhir:value "14975008" ]; fhir:Coding.display [ fhir:value "Forearm structure" ] ] ] ]; fhir:ServiceRequest.identifier [ fhir:index 0; fhir:Identifier.system [ fhir:value "http://www.bmc.nl/zorgportal/identifiers/labresults" ]; fhir:Identifier.value [ fhir:value "L2381" ] ]; fhir:ServiceRequest.status [ fhir:value "active"]; fhir:ServiceRequest.intent [ fhir:value "original-order"]; fhir:ServiceRequest.code [ fhir:CodeableReference.concept [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:58410-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "58410-2" ]; fhir:Coding.display [ fhir:value "Complete blood count (hemogram) panel - Blood by Automated count" ] ] ] ]; fhir:ServiceRequest.subject [ fhir:Reference.reference [ fhir:value "Patient/f001" ]; fhir:Reference.display [ fhir:value "P. van den Heuvel" ] ]; fhir:ServiceRequest.encounter [ fhir:Reference.reference [ fhir:value "Encounter/f001" ] ]; fhir:ServiceRequest.requester [ fhir:Reference.reference [ fhir:value "Practitioner/f001" ]; fhir:Reference.display [ fhir:value "E.van den Broek" ] ]; fhir:ServiceRequest.note [ fhir:index 0; fhir:Annotation.text [ fhir:value "patient almost fainted during procedure" ] ] . # - ontology header ------------------------------------------------------------ [a owl:Ontology; owl:imports fhir:fhir.ttl] . # -------------------------------------------------------------------------------------
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.