R6 Ballot (2nd Draft)

Publish-box (todo)

Example Observation/blood-pressure-dar (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)

Blood Pressure Measurement with an absent Diastolic measurement (id = "blood-pressure-dar")

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

<Observation xmlns="http://hl7.org/fhir">
  <id value="blood-pressure-dar"/> 
  <meta> 
    <profile value="http://hl7.org/fhir/StructureDefinition/vitalsigns"/> 
  </meta> 
  <identifier> 
    <system value="urn:ietf:rfc:3986"/> 
    <value value="urn:uuid:187e0c12-8dd2-67e2-99b2-bf273c878281"/> 
  </identifier> 
  <status value="final"/> 
  <category> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/observation-category"/> 
      <code value="vital-signs"/> 
      <display value="Vital Signs"/> 
    </coding> 
  </category> 
  <category> 
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="85354-9"/> 
      <display value="Blood pressure panel with all children optional"/> 
    </coding> 
  </category> 
  <code> 
    <!--   replaced by 85354-9
        <coding>
          <system value="http://loinc.org"/>
          <code value="85354-9"/>
          <display value="Blood pressure systolic &amp; diastolic"/>
        </coding>
      -->
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="85354-9"/> 
      <display value="Blood pressure panel with all children optional"/> 
    </coding> 
    <text value="Blood pressure systolic &amp; diastolic"/> 
  </code> 
  <subject> 
    <reference value="Patient/example"/> 
  </subject> 
  <effectiveDateTime value="2012-09-17"/> 
  <performer> 
    <reference value="Practitioner/example"/> 
  </performer> 
  <!--     an interpretation offered to the combination observation
        generally, it would only be appropriate to offer an interpretation
        of an observation that has no value if it has "COMP" (component)
        observations     -->
  <interpretation> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/> 
      <code value="L"/> 
      <display value="low"/> 
    </coding> 
    <text value="Below low normal"/> 
  </interpretation> 
  <!--  The BodySite can be captured in a LOINC code but am showing it here to demonstrate
   populating the element   -->
  <bodySite> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="368209003"/> 
      <display value="Right arm"/> 
    </coding> 
  </bodySite> 
  <!--      Should have a refrange as well    -->
  <component> 
    <extension url="http://hl7.org/fhir/StructureDefinition/observation-componentCategory">
      <valueCodeableConcept> 
        <coding> 
          <system value="http://loinc.org"/> 
          <code value="8480-6"/> 
          <display value="Systolic blood pressure"/> 
        </coding> 
      </valueCodeableConcept> 
    </extension> 
    <!--  
           Observations are often coded in multiple code systems.
           - LOINC provides a very specific code (though not more specific in this
     particular case)
           - snomed provides a clinically relevant code that is usually less granular
     than LOINC
           - the source system provides its own code, which may be less or more
     granular than LOINC

this is shown here to demonstrate  the concept of translations within the codeableConcept
     datatype. The diastolic code below only has a LOINC code
             -->
    <code> 
      <!--     LOINC -code     -->
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="8480-6"/> 
        <display value="Systolic blood pressure"/> 
      </coding> 
      <!--     SNOMED CT Codes     -->
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="271649006"/> 
        <display value="Systolic blood pressure"/> 
      </coding> 
      <!--     Also, a local code specific to the source system     -->
      <coding> 
        <system value="http://acme.org/devices/clinical-codes"/> 
        <code value="bp-s"/> 
        <display value="Systolic Blood pressure"/> 
      </coding> 
    </code> 
    <valueQuantity> 
      <value value="107"/> 
      <unit value="mmHg"/> 
      <system value="http://unitsofmeasure.org"/> 
      <code value="mm[Hg]"/> 
    </valueQuantity> 
  </component> 
  <!--      Should have a refrange as well    -->
  <component> 
    <extension url="http://hl7.org/fhir/StructureDefinition/observation-componentCategory">
      <valueCodeableConcept> 
        <coding> 
          <system value="http://loinc.org"/> 
          <code value="8462-4"/> 
          <display value="Diastolic blood pressure"/> 
        </coding> 
      </valueCodeableConcept> 
    </extension> 
    <code> 
      <coding> 
        <system value="http://loinc.org"/> 
        <code value="8462-4"/> 
        <display value="Diastolic blood pressure"/> 
      </coding> 
    </code> 
    <!--     Here the Diastolic measurement is missing and we give a reason using the DataAbsentReason
     element     -->
    <dataAbsentReason> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/data-absent-reason"/> 
        <code value="not-performed"/> 
        <display value="Not Performed"/> 
      </coding> 
    </dataAbsentReason> 
  </component> 
</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.