R6 Ballot (2nd Draft)

Publish-box (todo)

Example DiagnosticReport/f001 (JSON)

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

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

Real-world patient example

{
  "resourceType" : "Bundle",
  "id" : "f001",
  "type" : "collection",
  "entry" : [{
    "fullUrl" : "https://example.com/base/DiagnosticReport/f001",
    "resource" : {
      "resourceType" : "DiagnosticReport",
      "id" : "f001",
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport f001</b></p><a name=\"f001\"> </a><a name=\"hcf001\"> </a><a name=\"f001-en-AU\"> </a><h2><span title=\"Codes:{http://loinc.org 58410-2}\">CBC 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>Pieter van de Heuvel  male, DoB: 1944-11-17 ( urn:oid:2.16.840.1.113883.2.4.6.3#?ngen-9?\u00a0(use:\u00a0usual,\u00a0))</td></tr><tr><td>Reported</td><td>2013-05-15T19:32:52+01:00</td></tr><tr><td>Performer</td><td> <a href=\"organization-example-f001-burgers.html\">Burgers University Medical Centre</a></td></tr><tr><td>Identifier</td><td> <code>http://www.bmc.nl/zorgportal/identifiers/reports</code>/nr1239044\u00a0(use:\u00a0official,\u00a0)</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<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codemmol/L = 'mmol/L')</span></td><td>3.1 mmol/l<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codemmol/L = 'mmol/L')</span> - 6.2 mmol/l<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codemmol/L = 'mmol/L')</span></td><td>final, <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<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codemmol/L = 'mmol/L')</span></td><td>7.1 mmol/l<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codemmol/L = 'mmol/L')</span> - 11.2 mmol/l<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codemmol/L = 'mmol/L')</span></td><td>final, <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 [Partial pressure] in Blood</span></a></td><td>6.2 kPa<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codekPa = 'kPa')</span></td><td>4.8 kPa<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codekPa = 'kPa')</span> - 6.0 kPa<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codekPa = 'kPa')</span></td><td>final, <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<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  code10*12/L = '10*12/L')</span></td><td><div><p>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</p>\n</div></td><td>final, <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<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codeg/dL = 'g/dL')</span></td><td>7.5 g/dl<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codeg/dL = 'g/dL')</span> - 10 g/dl<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codeg/dL = 'g/dL')</span></td><td>final, <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><div><p>Core lab</p>\n</div></div>"
      },
      "identifier" : [{
        "use" : "official",
        "system" : "http://www.bmc.nl/zorgportal/identifiers/reports",
        "value" : "nr1239044"
      }],
      "basedOn" : [{
        "reference" : "ServiceRequest/req"
      }],
      "status" : "final",
      "category" : [{
        "coding" : [{
          "system" : "http://snomed.info/sct",
          "code" : "252275004",
          "display" : "Haematology test"
        },
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v2-0074",
          "code" : "HM"
        }]
      }],
      "code" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "58410-2",
          "display" : "CBC panel - Blood by Automated count"
        }]
      },
      "subject" : {
        "reference" : "Patient/f001",
        "display" : "P. van den Heuvel"
      },
      "issued" : "2013-05-15T19:32:52+01:00",
      "performer" : [{
        "reference" : "Organization/f001",
        "display" : "Burgers University Medical Centre"
      }],
      "result" : [{
        "reference" : "Observation/f001"
      },
      {
        "reference" : "Observation/f002"
      },
      {
        "reference" : "Observation/f003"
      },
      {
        "reference" : "Observation/f004"
      },
      {
        "reference" : "Observation/f005"
      }],
      "conclusion" : "Core lab"
    }
  },
  {
    "fullUrl" : "https://example.com/base/ServiceRequest/req",
    "resource" : {
      "resourceType" : "ServiceRequest",
      "id" : "req",
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ServiceRequest req</b></p><a name=\"req\"> </a><a name=\"hcreq\"> </a><a name=\"req-en-AU\"> </a><p><b>identifier</b>: <code>http://www.bmc.nl/zorgportal/identifiers/labresults</code>/L2381</p><p><b>status</b>: active</p><p><b>intent</b>: original-order</p><h3>Codes</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Concept</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://loinc.org 58410-2}\">CBC panel - Blood by Automated count</span></td></tr></table><p><b>subject</b>: <a href=\"patient-example-f001-pieter.html\">P. van den Heuvel</a></p><p><b>encounter</b>: <a href=\"encounter-example-f001-heart.html\">Encounter: identifier = http://www.amc.nl/zorgportal/identifiers/visits#v1451\u00a0(use:\u00a0official,\u00a0); status = completed; class = ambulatory; priority = Non-urgent cardiological admission; type = Patient-initiated encounter</a></p><p><b>requester</b>: <a href=\"practitioner-example-f001-evdb.html\">E.van den Broek</a></p><p><b>note</b>: patient almost fainted during procedure</p></div>"
      },
      "extension" : [{
        "url" : "http://example.org/bodysitecode",
        "valueCodeableConcept" : {
          "coding" : [{
            "system" : "http://snomed.info/sct",
            "code" : "14975008",
            "display" : "Forearm structure"
          }]
        }
      }],
      "identifier" : [{
        "system" : "http://www.bmc.nl/zorgportal/identifiers/labresults",
        "value" : "L2381"
      }],
      "status" : "active",
      "intent" : "original-order",
      "code" : {
        "concept" : {
          "coding" : [{
            "system" : "http://loinc.org",
            "code" : "58410-2",
            "display" : "CBC panel - Blood by Automated count"
          }]
        }
      },
      "subject" : {
        "reference" : "Patient/f001",
        "display" : "P. van den Heuvel"
      },
      "encounter" : {
        "reference" : "Encounter/f001"
      },
      "requester" : {
        "reference" : "Practitioner/f001",
        "display" : "E.van den Broek"
      },
      "note" : [{
        "text" : "patient almost fainted during procedure"
      }]
    }
  }]
}

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.