R6 Ballot (2nd Draft)

Publish-box (todo)

Example Observation/f202 (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)

Real-world patient - temperature (id = "f202")

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

<Observation xmlns="http://hl7.org/fhir">
  <id value="f202"/> 
  <!--   Oral temperature was measured on April fourth   -->
  <status value="entered-in-error"/> 
  <!--   category code is A code that classifies the general type of observation being
   made. This is used for searching, sorting and display purposes.  -->
  <category> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/observation-category"/> 
      <code value="vital-signs"/> 
      <display value="Vital Signs"/> 
    </coding> 
  </category> 
  <!--   "interoperability category" code   -->
  <category> 
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="8310-5"/> 
      <display value="Body temperature"/> 
    </coding> 
  </category> 
  <code> 
    <!--   Kind of observation = Temperature   -->
    <!--   local code here   -->
    <coding> 
      <system value="http://acme.lab"/> 
      <code value="BT"/> 
      <display value="Body temperature"/> 
    </coding> 
    <!--   LOINC and SNOMED CT translations here - Note in the US the primary code will
     be LOINC per meaningful use.  Further SNOMED CT  has acceeded to LOINC being the
     primary coding system for vitals and anthropromorphic measures.  SNOMED CT is required
     in some countries such as the UK.  -->
    <!--   the measurement LOINC code is more specific than the "interoperability category"
     code (by system - ie oral temp) this example shows how the  LOINC or method element
     could be used to convey the same information both not necessary in most cases  -->
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="8331-1"/> 
      <display value="Oral temperature"/> 
    </coding> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="56342008"/> 
      <display value="Temperature taking"/> 
    </coding> 
    <text value="Temperature"/> 
  </code> 
  <!--   No identifier could be provided to this observation   -->
  <subject> 
    <reference value="Patient/f201"/> 
    <display value="Roel"/> 
  </subject> 
  <issued value="2013-04-04T13:27:00+01:00"/> 
  <performer> 
    <reference value="Practitioner/f201"/> 
  </performer> 
  <valueQuantity> 
    <!--   Temperature=39 degrees Celsius   -->
    <value value="39"/> 
    <unit value="degrees C"/> 
    <system value="http://unitsofmeasure.org"/> 
    <code value="Cel"/> 
  </valueQuantity> 
  <interpretation> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/> 
      <code value="H"/> 
    </coding> 
  </interpretation> 
  <!--   In the meantime a new oral temperature is measured   -->
  <!--   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3418963/   -->
  <bodySite> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="74262004"/> 
      <display value="Oral cavity"/> 
    </coding> 
  </bodySite> 
  <method> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="89003005"/> 
      <display value="Oral temperature taking"/> 
    </coding> 
  </method> 
  <referenceRange> 
    <!--    0..* Provides guide for interpretation    -->
    <high> 
      <value value="38.2"/> 
      <unit value="degrees C"/> 
    </high> 
  </referenceRange> 
</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.