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Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner |
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An example of a comprehensive bone marrow report
{ "resourceType": "Bundle", "id": "report", "type": "collection", "entry": [ { "fullUrl": "https://example.com/base/DiagnosticReport/report", "resource": { "resourceType": "DiagnosticReport", "id": "report", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: report</p><p><b>status</b>: final</p><p><b>code</b>: comprehensive bone marrow report <span>(Details )</span></p><p><b>subject</b>: <a>Everywoman, Eve A, MRN: 123456789</a></p><p><b>effective</b>: 02/01/2015 1:20:10 PM</p><p><b>issued</b>: 06/01/2015 1:20:10 PM</p><p><b>performer</b>: <a>Molecular Diagnostic Laboratory</a></p><p><b>specimen</b>: <a>Bone marrow ID: MLD45-Z4-1234</a></p><p><b>result</b>: </p><ul><li><a>Observation/o1</a></li><li><a>Observation/o2</a></li><li><a>Observation/o3</a></li><li><a>Observation/o4</a></li><li><a>Observation/o5</a></li><li><a>Observation/o6</a></li><li><a>Observation/o7</a></li><li><a>Observation/o8</a></li><li><a>Observation/o9</a></li><li><a>Observation/o10</a></li><li><a>Observation/o11</a></li><li><a>Observation/o12</a></li><li><a>Observation/o13</a></li></ul></div>" }, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport-geneticsAssessedCondition", "valueReference": { "reference": "Condition/c1" } } ], "status": "final", "code": { "text": "comprehensive bone marrow report" }, "subject": { "reference": "Patient/genetics-example1", "display": "Everywoman, Eve A, MRN: 123456789" }, "effectiveDateTime": "2015-01-02T13:20:10+01:00", "issued": "2015-01-06T13:20:10+01:00", "performer": [ { "reference": "Practitioner/genetics-example1", "display": "Molecular Diagnostic Laboratory" } ], "specimen": [ { "reference": "Specimen/genetics-example1", "display": "Bone marrow ID: MLD45-Z4-1234" } ], "result": [ { "reference": "Observation/o1" }, { "reference": "Observation/o2" }, { "reference": "Observation/o3" }, { "reference": "Observation/o4" }, { "reference": "Observation/o5" }, { "reference": "Observation/o6" }, { "reference": "Observation/o7" }, { "reference": "Observation/o8" }, { "reference": "Observation/o9" }, { "reference": "Observation/o10" }, { "reference": "Observation/o11" }, { "reference": "Observation/o12" }, { "reference": "Observation/o13" } ] } }, { "fullUrl": "https://example.com/base/Observation/o1", "resource": { "resourceType": "Observation", "id": "o1", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o1</p><p><b>status</b>: final</p><p><b>code</b>: Leukocytes [#/volume] in Blood <span>(Details : {LOINC code '26464-8' = 'Leukocytes [#/volume] in Blood', given as 'Leukocytes [#/volume] in Blood'})</span></p><p><b>value</b>: 31.9 K/ul</p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "26464-8", "display": "Leukocytes [#/volume] in Blood" } ] }, "valueQuantity": { "value": 31.9, "unit": "K/ul" } } }, { "fullUrl": "https://example.com/base/Observation/o2", "resource": { "resourceType": "Observation", "id": "o2", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o2</p><p><b>status</b>: final</p><p><b>code</b>: Hematocrit [Volume Fraction] of Blood <span>(Details : {LOINC code '20570-8' = 'Hematocrit [Volume Fraction] of Blood', given as 'Hematocrit [Volume Fraction] of Blood'})</span></p><p><b>value</b>: 27 %</p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "20570-8", "display": "Hematocrit [Volume Fraction] of Blood" } ] }, "valueQuantity": { "value": 27, "unit": "%" } } }, { "fullUrl": "https://example.com/base/Observation/o3", "resource": { "resourceType": "Observation", "id": "o3", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o3</p><p><b>status</b>: final</p><p><b>code</b>: Platelets [#/volume] in Blood <span>(Details : {LOINC code '26515-7' = 'Platelets [#/volume] in Blood', given as 'Platelets [#/volume] in Blood'})</span></p><p><b>value</b>: 84 K/ul</p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "26515-7", "display": "Platelets [#/volume] in Blood" } ] }, "valueQuantity": { "value": 84, "unit": "K/ul" } } }, { "fullUrl": "https://example.com/base/Observation/o4", "resource": { "resourceType": "Observation", "id": "o4", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o4</p><p><b>status</b>: final</p><p><b>code</b>: NPM1 gene mutations found [Identifier] in Bone marrow by Molecular genetics method Nominal <span>(Details : {LOINC code '75034-9' = 'NPM1 gene mutations found [Identifier] in Bone marrow by Molecular genetics method Nominal', given as 'NPM1 gene mutations found [Identifier] in Bone marrow by Molecular genetics method Nominal'})</span></p><p><b>value</b>: Positive <span>(Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span></p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "75034-9", "display": "NPM1 gene mutations found [Identifier] in Bone marrow by Molecular genetics method Nominal" } ] }, "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "10828004", "display": "Positive" } ] } } }, { "fullUrl": "https://example.com/base/Observation/o5", "resource": { "resourceType": "Observation", "id": "o5", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o5</p><p><b>status</b>: final</p><p><b>code</b>: FLT3 gene mutation analysis in Bone marrow by Molecular genetics method Narrative <span>(Details : {LOINC code '54447-8' = 'FLT3 gene mutation analysis in Bone marrow by Molecular genetics method Narrative', given as 'FLT3 gene mutation analysis in Bone marrow by Molecular genetics method Narrative'})</span></p><p><b>value</b>: Negative <span>(Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span></p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "54447-8", "display": "FLT3 gene mutation analysis in Bone marrow by Molecular genetics method Narrative" } ] }, "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative" } ] } } }, { "fullUrl": "https://example.com/base/Observation/o6", "resource": { "resourceType": "Observation", "id": "o6", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o6</p><p><b>status</b>: final</p><p><b>code</b>: KIT gene mutation analysis in Bone marrow by Molecular genetics method Narrative <span>(Details : {LOINC code '55201-8' = 'KIT gene mutation analysis in Blood or Tissue by Molecular genetics method Narrative', given as 'KIT gene mutation analysis in Bone marrow by Molecular genetics method Narrative'})</span></p><p><b>value</b>: Negative <span>(Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span></p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "55201-8", "display": "KIT gene mutation analysis in Bone marrow by Molecular genetics method Narrative" } ] }, "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative" } ] } } }, { "fullUrl": "https://example.com/base/Observation/o7", "resource": { "resourceType": "Observation", "id": "o7", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o7</p><p><b>status</b>: final</p><p><b>code</b>: Myeloblasts [#/volume] in Blood <span>(Details : {LOINC code '30444-4' = 'Myeloblasts [#/volume] in Blood', given as 'Myeloblasts [#/volume] in Blood'})</span></p><p><b>value</b>: Positive <span>(Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span></p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "30444-4", "display": "Myeloblasts [#/volume] in Blood" } ] }, "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "10828004", "display": "Positive" } ] } } }, { "fullUrl": "https://example.com/base/Observation/o8", "resource": { "resourceType": "Observation", "id": "o8", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o8</p><p><b>status</b>: final</p><p><b>code</b>: CD4 Ag [Presence] in Tissue by Immune stain <span>(Details : {LOINC code '47016-1' = 'CD4 Ag [Presence] in Tissue by Immune stain', given as 'CD4 Ag [Presence] in Tissue by Immune stain'})</span></p><p><b>value</b>: Positive <span>(Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span></p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "47016-1", "display": "CD4 Ag [Presence] in Tissue by Immune stain" } ] }, "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "10828004", "display": "Positive" } ] } } }, { "fullUrl": "https://example.com/base/Observation/o9", "resource": { "resourceType": "Observation", "id": "o9", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o9</p><p><b>status</b>: final</p><p><b>code</b>: CD13 Ag [Presence] in Tissue by Immune stain <span>(Details : {LOINC code '49464-1' = 'CD13 Ag [Presence] in Tissue by Immune stain', given as 'CD13 Ag [Presence] in Tissue by Immune stain'})</span></p><p><b>value</b>: Positive <span>(Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span></p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "49464-1", "display": "CD13 Ag [Presence] in Tissue by Immune stain" } ] }, "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "10828004", "display": "Positive" } ] } } }, { "fullUrl": "https://example.com/base/Observation/o10", "resource": { "resourceType": "Observation", "id": "o10", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o10</p><p><b>status</b>: final</p><p><b>code</b>: CD2 Ag [Presence] in Tissue by Immune stain <span>(Details : {LOINC code '49466-6' = 'CD2 Ag [Presence] in Tissue by Immune stain', given as 'CD2 Ag [Presence] in Tissue by Immune stain'})</span></p><p><b>value</b>: Negative <span>(Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span></p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "49466-6", "display": "CD2 Ag [Presence] in Tissue by Immune stain" } ] }, "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative" } ] } } }, { "fullUrl": "https://example.com/base/Observation/o11", "resource": { "resourceType": "Observation", "id": "o11", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o11</p><p><b>status</b>: final</p><p><b>code</b>: Karyotype [Identifier] in Bone marrow Nominal <span>(Details : {LOINC code '33893-9' = 'Karyotype [Identifier] in Bone marrow Nominal', given as 'Karyotype [Identifier] in Bone marrow Nominal'})</span></p><p><b>value</b>: 46,XX[20] <span>(Details )</span></p></div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "33893-9", "display": "Karyotype [Identifier] in Bone marrow Nominal" } ] }, "valueCodeableConcept": { "text": "46,XX[20]" } } }, { "fullUrl": "https://example.com/base/Observation/o12", "resource": { "resourceType": "Observation", "id": "o12", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o12</p><p><b>status</b>: final</p><p><b>code</b>: MDS-associated genetic abnormalities <span>(Details )</span></p><p><b>value</b>: Negative <span>(Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span></p></div>" }, "status": "final", "code": { "text": "MDS-associated genetic abnormalities" }, "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative" } ] } } }, { "fullUrl": "https://example.com/base/Observation/o13", "resource": { "resourceType": "Observation", "id": "o13", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: o13</p><p><b>status</b>: final</p><p><b>code</b>: AML-associated genetic abnormalities <span>(Details )</span></p><p><b>value</b>: Negative <span>(Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span></p></div>" }, "status": "final", "code": { "text": "AML-associated genetic abnormalities" }, "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "260385009", "display": "Negative" } ] } } } ] }
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.