R5 Final QA

This page is part of the FHIR Specification (v5.0.0-draft-final: Final QA Preview for R5 - see ballot notes). 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

Example Observation/abdo-tender (XML)

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Raw XML (canonical form + also see XML Format Specification)

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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: Observation</b> <a name="abdo-tender"> </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 Observation &quot;abdo-tender&quot; </p> </div> <p> <b> status</b> : final</p> <p> <b> category</b> : Exam <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-observation-category.html">Observation Category Codes</a> #exam)</span> </p> <p> <b> code</b> : Abdominal tenderness <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a> #43478001 &quot;Abdominal tenderness (finding)&quot;)</span> </p> <p> <b> subject</b> : <a href="patient-example.html">Patient/example</a>  &quot;Peter CHALMERS&quot;</p> <p> <b> encounter</b> : <a href="encounter-example.html">Encounter/example</a> </p> <p> <b> effective</b> : 2018-04-02T10:30:10+01:00 --&gt; (ongoing)</p> <p> <b> issued</b> : 4 Apr 2018, 12:30:10 am</p> <p> <b> value</b> : true</p> <p> <b> interpretation</b> : Abnormal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/4.0.0/CodeSystem-v3-ObservationInterpretation.html">ObservationInterpretation</a> #A)</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.