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Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner |
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An example of a principally narrative anatomic pathology report
@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 xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- [a fhir:DiagnosticReport; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "pap"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "additional" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Acme Anatomic Pathology Services<br/>2216 Santa Monica Blvd, Suite 114<br/>Santa Monica, CA 90404<br/>===============================================================<br/>GYN CYTOLOGY (PAP SMEAR) REPORT<br/>===============================================================</p>\n <p>Patient: Everywoman, Eve Report Date: 2/14/2013<br/>DOB: 05/31/1973 Age: 30 Sex: F MRN: PATID14567<br/>Patient Address: 2222 Home Street<br/> Huntington Park<br/> CA 90255<br/>Order: ORD40<br/>Physician: Careful, Adam 5742200012 (NPI)<br/>SpecimenID: GHSID40<br/>Collected Date: 2/11/2013<br/>Received Date: 2/12/2013<br/>LMP: 1/28/2013<br/>Specimen Source: Cervical Cytology (ThinPrep)<br/>Previously abnormal Pap? Unknown</p>\n <p>Specimen Adequacy: Satisfactory<br/>Diagnostic Interpretation: Epithelial cell abnormality: Atypical squamous cells<br/>of undetermined significance<br/>Hormonal Evaluations: not possible, due to presence of atypical cells<br/>Recommendations: Appropriate Follow-up. Suggest repeat as clinically indicated<br/>Comments: Abnormal report reviewed by pathologist for confirmation</p>\n <p/>\n </div>" ]; fhir:DiagnosticReport.status [ fhir:value "final"]; fhir:DiagnosticReport.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:47527-7; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "47527-7" ] ] ]; fhir:DiagnosticReport.subject [ fhir:Reference.reference [ fhir:value "Patient/b248b1b2-1686-4b94-9936-37d7a5f94b51" ] ]; fhir:DiagnosticReport.effectiveDateTime [ fhir:value "2013-02-11T10:33:33+11:00"^^xsd:dateTime]; fhir:DiagnosticReport.issued [ fhir:value "2013-02-13T11:45:33+11:00"^^xsd:dateTime]; fhir:DiagnosticReport.performer [ fhir:index 0; fhir:Reference.reference [ fhir:value "Practitioner/example" ] ]] . # - 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.