R6 Ballot (2nd Draft)

Publish-box (todo)

Example DiagnosticReport/f001 (XML)

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

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

Real-world patient example (id = "f001")

<?xml version="1.0" encoding="UTF-8"?>

<Bundle xmlns="http://hl7.org/fhir">
  <id value="f001"/> 
  <type value="collection"/> 
  <entry> 
    <fullUrl value="https://example.com/base/DiagnosticReport/f001"/> 
    <resource> 
      <DiagnosticReport> 
        <!--    ISO 8601    -->
        <!--    OID: 2.16.840.1.113883.4.642.1.7    -->
        <id value="f001"/> 
        <text> 
          <status value="generated"/> <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? (use
                  : usual, ))</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 (use: 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<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> 
</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> 
</div> </div> 
        </text> 
        <identifier> 
          <use value="official"/> 
          <system value="http://www.bmc.nl/zorgportal/identifiers/reports"/> 
          <value value="nr1239044"/> 
        </identifier> 
        <basedOn> 
          <reference value="ServiceRequest/req"/> 
        </basedOn> 
        <status value="final"/> 
        <category> 
          <coding> 
            <system value="http://snomed.info/sct"/> 
            <code value="252275004"/> 
            <display value="Haematology test"/> 
          </coding> 
          <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/> 
            <code value="HM"/> 
          </coding> 
        </category> 
        <code> 
          <coding> 
            <system value="http://loinc.org"/> 
            <code value="58410-2"/> 
            <display value="CBC panel - Blood by Automated count"/> 
          </coding> 
        </code> 
        <subject> 
          <reference value="Patient/f001"/> 
          <display value="P. van den Heuvel"/> 
        </subject> 
        <issued value="2013-05-15T19:32:52+01:00"/> 
        <performer> 
          <reference value="Organization/f001"/> 
          <display value="Burgers University Medical Centre"/> 
        </performer> 
        <result> 
          <reference value="Observation/f001"/> 
        </result> 
        <result> 
          <reference value="Observation/f002"/> 
        </result> 
        <result> 
          <reference value="Observation/f003"/> 
        </result> 
        <result> 
          <reference value="Observation/f004"/> 
        </result> 
        <result> 
          <reference value="Observation/f005"/> 
        </result> 
        <conclusion value="Core lab"/> 
      </DiagnosticReport> 
    </resource> 
  </entry> 
  <entry> 
    <fullUrl value="https://example.com/base/ServiceRequest/req"/> 
    <resource> 
      <ServiceRequest> 
        <id value="req"/> 
        <text> 
          <status value="generated"/> <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 (use: official,
                 ); 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> 
        </text> 
        <extension url="http://example.org/bodysitecode">
          <valueCodeableConcept> 
            <coding> 
              <system value="http://snomed.info/sct"/> 
              <code value="14975008"/> 
              <display value="Forearm structure"/> 
            </coding> 
          </valueCodeableConcept> 
        </extension> 
        <identifier> 
          <system value="http://www.bmc.nl/zorgportal/identifiers/labresults"/> 
          <value value="L2381"/> 
        </identifier> 
        <status value="active"/> 
        <intent value="original-order"/> 
        <code> 
          <concept> 
            <coding> 
              <system value="http://loinc.org"/> 
              <code value="58410-2"/> 
              <display value="CBC panel - Blood by Automated count"/> 
            </coding> 
          </concept> 
        </code> 
        <subject> 
          <reference value="Patient/f001"/> 
          <display value="P. van den Heuvel"/> 
        </subject> 
        <encounter> 
          <reference value="Encounter/f001"/> 
        </encounter> 
        <requester> 
          <reference value="Practitioner/f001"/> 
          <display value="E.van den Broek"/> 
        </requester> 
        <note> 
          <text value="patient almost fainted during procedure"/> 
        </note> 
      </ServiceRequest> 
    </resource> 
  </entry> 
</Bundle> 

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.