FHIR Release 3 (STU)

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Diagnosticreport-genetics-comprehensive-bone-marrow-report.xml

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

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An example of a comprehensive bone marrow report (id = "report")

<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="report"/> 
  <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : report</p> <p> <b> contained</b> : , , , , , , , , , , , , </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> <h3> Performers</h3> <table> <tr> <td> -</td> <td> <b> Actor</b> </td> </tr> <tr> <td> *</td> <td> <a> Molecular Diagnostic Laboratory</a> </td> </tr> </table> <p> <b> specimen</b> : <a> Bone marrow ID: MLD45-Z4-1234</a> </p> <p> <b> result</b> : </p> <ul> <li> id: o1; status: final; Leukocytes [#/volume] in Blood <span> (Details : {LOINC code '26464-8' = 'Leukocytes [#/volume] in Blood', given as 'Leukocytes
             [#/volume] in Blood'})</span> ; 31.9 K/ul</li> <li> id: o2; status: final; Hematocrit [Volume Fraction] of Blood <span> (Details : {LOINC code '20570-8' = 'Hematocrit [Volume Fraction] of Blood', given as 'Hematocrit
             [Volume Fraction] of Blood'})</span> ; 27 %</li> <li> id: o3; status: final; Platelets [#/volume] in Blood <span> (Details : {LOINC code '26515-7' = 'Platelets [#/volume] in Blood', given as 'Platelets
             [#/volume] in Blood'})</span> ; 84 K/ul</li> <li> id: o4; status: final; 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> ; Positive <span> (Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span> </li> <li> id: o5; status: final; 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> ; Negative <span> (Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span> </li> <li> id: o6; status: final; 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> ; Negative <span> (Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span> </li> <li> id: o7; status: final; Myeloblasts [#/volume] in Blood <span> (Details : {LOINC code '30444-4' = 'Myeloblasts [#/volume] in Blood', given as 'Myeloblasts
             [#/volume] in Blood'})</span> ; Positive <span> (Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span> </li> <li> id: o8; status: final; 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> ; Positive <span> (Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span> </li> <li> id: o9; status: final; 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> ; Positive <span> (Details : {SNOMED CT code '10828004' = 'Positive', given as 'Positive'})</span> </li> <li> id: o10; status: final; 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> ; Negative <span> (Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span> </li> <li> id: o11; status: final; 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> ; 46,XX[20] <span> (Details )</span> </li> <li> id: o12; status: final; MDS-associated genetic abnormalities <span> (Details )</span> ; Negative <span> (Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span> </li> <li> id: o13; status: final; AML-associated genetic abnormalities <span> (Details )</span> ; Negative <span> (Details : {SNOMED CT code '260385009' = 'Negative', given as 'Negative'})</span> </li> </ul> </div> </text> <contained> 
      <Observation> 
          <id value="o1"/> 
          <status value="final"/> 
          <code> 
              <coding> 
                  <system value="http://loinc.org"/> 
                  <code value="26464-8"/> 
                  <display value="Leukocytes [#/volume] in Blood"/> 
              </coding> 
          </code> 
          <valueQuantity> 
              <value value="31.9"/> 
              <unit value="K/ul"/> 
          </valueQuantity> 
      </Observation> 
  </contained> 
  <contained> 
      <Observation> 
          <id value="o2"/> 
          <status value="final"/> 
          <code> 
              <coding> 
                  <system value="http://loinc.org"/> 
                  <code value="20570-8"/> 
                  <display value="Hematocrit [Volume Fraction] of Blood"/> 
              </coding> 
          </code> 
          <valueQuantity> 
              <value value="27"/> 
              <unit value="%"/> 
          </valueQuantity> 
      </Observation> 
  </contained> 
  <contained> 
      <Observation> 
          <id value="o3"/> 
          <status value="final"/> 
          <code> 
              <coding> 
                  <system value="http://loinc.org"/> 
                  <code value="26515-7"/> 
                  <display value="Platelets [#/volume] in Blood"/> 
              </coding> 
          </code> 
          <valueQuantity> 
              <value value="84"/> 
              <unit value="K/ul"/> 
          </valueQuantity> 
      </Observation> 
  </contained> 
  <contained> 
      
      <Observation> 
          <id value="o4"/> 
          <status value="final"/> 
          <code> 
              <coding> 
                  <system value="http://loinc.org"/> 
                  <code value="75034-9"/> 
                  <display value="NPM1 gene mutations found [Identifier] in Bone marrow by Molecular genetics method Nominal"/> 
              </coding> 
          </code> 
          <valueCodeableConcept> 
              <coding> 
                  <system value="http://snomed.info/sct"/> 
                  <code value="10828004"/> 
                  <display value="Positive"/> 
              </coding> 
          </valueCodeableConcept> 
      </Observation> 
  </contained> 
  <contained> 
      <Observation> 
          <id value="o5"/> 
          <status value="final"/> 
          <code> 
              <coding> 
                  <system value="http://loinc.org"/> 
                  <code value="54447-8"/> 
                  <display value="FLT3 gene mutation analysis in Bone marrow by Molecular genetics method Narrative"/> 
              </coding> 
          </code> 
          <valueCodeableConcept> 
              <coding> 
                  <system value="http://snomed.info/sct"/> 
                  <code value="260385009"/> 
                  <display value="Negative"/> 
              </coding> 
          </valueCodeableConcept> 
      </Observation> 
  </contained> 
  <contained> 
      <Observation> 
          <id value="o6"/> 
          <status value="final"/> 
          <code> 
              <coding> 
                  <system value="http://loinc.org"/> 
                  <code value="55201-8"/> 
                  <display value="KIT gene mutation analysis in Bone marrow by Molecular genetics method Narrative"/> 
              </coding> 
          </code> 
          <valueCodeableConcept> 
              <coding> 
                  <system value="http://snomed.info/sct"/> 
                  <code value="260385009"/> 
                  <display value="Negative"/> 
              </coding> 
          </valueCodeableConcept> 
      </Observation> 
  </contained> 
  <contained> 
      <Observation> 
          <id value="o7"/> 
          <status value="final"/> 
          <code> 
              <coding> 
                  <system value="http://loinc.org"/> 
                  <code value="30444-4"/> 
                  <display value="Myeloblasts [#/volume] in Blood"/> 
              </coding> 
          </code> 
          <valueCodeableConcept> 
              <coding> 
                  <system value="http://snomed.info/sct"/> 
                  <code value="10828004"/> 
                  <display value="Positive"/> 
              </coding> 
          </valueCodeableConcept> 
      </Observation> 
  </contained> 
  <contained> 
      <Observation> 
          <id value="o8"/> 
          <status value="final"/> 
          <code> 
              <coding> 
                  <system value="http://loinc.org"/> 
                  <code value="47016-1"/> 
                  <display value="CD4 Ag [Presence] in Tissue by Immune stain"/> 
              </coding> 
          </code> 
          <valueCodeableConcept> 
              <coding> 
                  <system value="http://snomed.info/sct"/> 
                  <code value="10828004"/> 
                  <display value="Positive"/> 
              </coding> 
          </valueCodeableConcept> 
      </Observation> 
  </contained> 
  <contained> 
      <Observation> 
          <id value="o9"/> 
          <status value="final"/> 
          <code> 
              <coding> 
                  <system value="http://loinc.org"/> 
                  <code value="49464-1"/> 
                  <display value="CD13 Ag [Presence] in Tissue by Immune stain"/> 
              </coding> 
          </code> 
          <valueCodeableConcept> 
              <coding> 
                  <system value="http://snomed.info/sct"/> 
                  <code value="10828004"/> 
                  <display value="Positive"/> 
              </coding> 
          </valueCodeableConcept> 
      </Observation> 
  </contained> 
  <contained> 
      <Observation> 
          <id value="o10"/> 
          <status value="final"/> 
          <code> 
              <coding> 
                  <system value="http://loinc.org"/> 
                  <code value="49466-6"/> 
                  <display value="CD2 Ag [Presence] in Tissue by Immune stain"/> 
              </coding> 
          </code> 
          <valueCodeableConcept> 
              <coding> 
                  <system value="http://snomed.info/sct"/> 
                  <code value="260385009"/> 
                  <display value="Negative"/> 
              </coding> 
          </valueCodeableConcept> 
      </Observation> 
  </contained> 
  <contained> 
      <Observation> 
          <id value="o11"/> 
          <status value="final"/> 
          <code> 
              <coding> 
                  <system value="http://loinc.org"/> 
                  <code value="33893-9"/> 
                  <display value="Karyotype [Identifier] in Bone marrow Nominal"/> 
              </coding> 
          </code> 
          <valueCodeableConcept> 
              <text value="46,XX[20]"/> 
          </valueCodeableConcept> 
      </Observation> 
  </contained> 
  <contained> 
      <Observation> 
          <id value="o12"/> 
          <status value="final"/> 
          <code> 
              <text value="MDS-associated genetic abnormalities"/> 
          </code> 
          <valueCodeableConcept> 
              <coding> 
                  <system value="http://snomed.info/sct"/> 
                  <code value="260385009"/> 
                  <display value="Negative"/> 
              </coding> 
          </valueCodeableConcept> 
      </Observation> 
  </contained> 
  <contained> 
      <Observation> 
          <id value="o13"/> 
          <status value="final"/> 
          <code> 
              <text value="AML-associated genetic abnormalities"/> 
          </code> 
          <valueCodeableConcept> 
              <coding> 
                  <system value="http://snomed.info/sct"/> 
                  <code value="260385009"/> 
                  <display value="Negative"/> 
              </coding> 
          </valueCodeableConcept> 
      </Observation> 
  </contained> 
  
  <extension url="http://hl7.org/fhir/StructureDefinition/DiagnosticReport-geneticsAssessedCondition">
      <valueReference> 
          <reference value="c1"/> 
      </valueReference> 
  </extension> 


  <status value="final"/> 
  <code> 
      <text value="comprehensive bone marrow report"/> 
  </code> 
  <subject> 
    <reference value="Patient/genetics-example1"/> 
    <display value="Everywoman, Eve A, MRN: 123456789"/> 
  </subject> 
  <effectiveDateTime value="2015-01-02T13:20:10+01:00"/> 
  <issued value="2015-01-06T13:20:10+01:00"/> 
  <performer> 
    <actor> 
      <reference value="Practitioner/genetics-example1"/> 
      <display value="Molecular Diagnostic Laboratory"/> 
    </actor> 
  </performer> 
  <specimen> 
    <reference value="Specimen/genetics-example1"/> 
    <display value="Bone marrow ID: MLD45-Z4-1234"/> 
  </specimen> 
  <result> 
      <reference value="#o1"/> 
  </result> 
  <result> 
      <reference value="#o2"/> 
  </result> 
  <result> 
      <reference value="#o3"/> 
  </result> 
  <result> 
      <reference value="#o4"/> 
  </result> 
  <result> 
      <reference value="#o5"/> 
  </result> 
  <result> 
      <reference value="#o6"/> 
  </result> 
  <result> 
      <reference value="#o7"/> 
  </result> 
  <result> 
      <reference value="#o8"/> 
  </result> 
  <result> 
      <reference value="#o9"/> 
  </result> 
  <result> 
      <reference value="#o10"/> 
  </result> 
  <result> 
      <reference value="#o11"/> 
  </result> 
  <result> 
      <reference value="#o12"/> 
  </result> 
  <result> 
      <reference value="#o13"/> 
  </result> 

</DiagnosticReport>

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.