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Example Procedure/biopsy (XML)

Patient Care Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Encounter, Patient, Practitioner, RelatedPerson

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

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Example of a Biopsy (id = "biopsy")

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

<Procedure xmlns="http://hl7.org/fhir">
  <id value="biopsy"/> 
  <text> 
    <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">Biopsy of suspected melanoma L) arm</div> 
  </text> 
  <status value="completed"/> 
  <category> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="103693007"/> 
      <display value="Diagnostic procedure (procedure)"/> 
    </coding> 
    <text value="Diagnostic procedure"/> 
  </category> 
  <code> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="90105005"/> 
      <display value="Biopsy of soft tissue of forearm, superficial"/> 
    </coding> 
    <text value="Biopsy of suspected melanoma L) arm"/> 
  </code> 
  <subject> 
    <reference value="Patient/example"/> 
  </subject> 
  <occurrenceDateTime value="2014-02-03"/> 
  <recorded value="2014-02-03"/> 
  <performer> 
    <actor> 
      <reference value="Practitioner/example"/> 
      <display value="Dr Bert Biopser"/> 
    </actor> 
  </performer> 
  <reason> 
    <concept> 
      <text value="Dark lesion l) forearm. getting darker last 3 months."/> 
    </concept> 
  </reason> 
  <!--   
  <bodySite>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="368225008"/>
        <display value="Entire Left Forearm"/>
      </coding>
      <text value="Left forearm"/>
  </bodySite>
    -->
  <bodyStructure> 
    <reference value="BodyStructure/skin-patch"/> 
  </bodyStructure> 
  <complication> 
    <concept> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="67750007"/> 
        <display value="Ineffective airway clearance (finding)"/> 
      </coding> 
      <text value="Ineffective airway clearance"/> 
    </concept> 
  </complication> 
  <followUp> 
    <concept> 
      <text value="Review in clinic"/> 
    </concept> 
  </followUp> 
  <note> 
    <text value="Standard Biopsy"/> 
  </note> 
  <used> 
    <concept> 
      <coding> 
        <system value="http://snomed.info/sct"/> 
        <code value="79068005"/> 
        <display value="Needle, device (physical object)"/> 
      </coding> 
      <text value="30-guage needle"/> 
    </concept> 
  </used> 
</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.