QI-Core Implementation Guide
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This page is part of the Quality Improvement Core Framework (v7.0.0-ballot: STU7 (v7.0.0) Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 6.0.0. For a full list of available versions, see the Directory of published versions

: Observation example - JSON Representation

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{
  "resourceType" : "Observation",
  "id" : "example",
  "meta" : {
    "profile" : [
      🔗 "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-simple-observation"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Observation example</b></p><a name=\"example\"> </a><a name=\"hcexample\"> </a><a name=\"example-en-US\"> </a><p><b>status</b>: Final</p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/observation-category vital-signs}\">Vital Signs</span></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 30350-3}\">Hemoglobin [Mass/volume] in Venous blood</span></p><p><b>subject</b>: <a href=\"Patient-example.html\">Jim Chalmers  Male, DoB: 1974-12-25 ( Medical record number\u00a0(use:\u00a0usual,\u00a0period:\u00a02001-05-06 --&gt; (ongoing)))</a></p><p><b>encounter</b>: <a href=\"Encounter-example.html\">Encounter: status = in-progress; class = inpatient encounter (ActCode#IMP); type = Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.</a></p><p><b>effective</b>: 2013-04-02 10:30:10+0100 --&gt; 2013-04-05 10:30:10+0100</p><p><b>issued</b>: 2013-04-03 15:30:10+0100</p><p><b>performer</b>: <a href=\"Practitioner-example.html\">Practitioner</a></p><p><b>value</b>: 7.2 g/dl<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codeg/dL = 'g/dL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0078 L}\">Below low normal</span></p><p><b>bodySite</b>: <span title=\"Codes:{http://snomed.info/sct 308046002}\">Superficial forearm vein</span></p><p><b>method</b>: <span title=\"Codes:{http://snomed.info/sct 120220003}\">Injection to forearm</span></p><p><b>derivedFrom</b>: <a href=\"Observation-example.html\">Observation Hemoglobin [Mass/volume] in Venous blood</a></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 8480-6}, {http://snomed.info/sct 271649006}\">Systolic blood pressure</span></p><p><b>value</b>: 107 mmHg<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codemm[Hg] = 'mm[Hg]')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0078 N}\">Normal</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 8462-4}\">Diastolic blood pressure</span></p><p><b>value</b>: 60 mmHg<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codemm[Hg] = 'mm[Hg]')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0078 L}\">Below low normal</span></p></blockquote></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/observation-bodyPosition",
      "valueCodeableConcept" : {
        "coding" : [
          {
            "system" : "http://snomed.info/sct",
            "code" : "33586001",
            "display" : "Sitting position (finding)"
          }
        ]
      }
    }
  ],
  "status" : "final",
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/observation-category",
          "code" : "vital-signs",
          "display" : "Vital Signs"
        }
      ]
    }
  ],
  "code" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "30350-3",
        "display" : "Hemoglobin [Mass/volume] in Venous blood"
      }
    ]
  },
  "subject" : {
    🔗 "reference" : "Patient/example"
  },
  "encounter" : {
    🔗 "reference" : "Encounter/example"
  },
  "effectivePeriod" : {
    "start" : "2013-04-02T10:30:10+01:00",
    "end" : "2013-04-05T10:30:10+01:00"
  },
  "issued" : "2013-04-03T15:30:10+01:00",
  "performer" : [
    {
      🔗 "reference" : "Practitioner/example",
      "display" : "Practitioner"
    }
  ],
  "valueQuantity" : {
    "value" : 7.2,
    "unit" : "g/dl",
    "system" : "http://unitsofmeasure.org",
    "code" : "g/dL"
  },
  "interpretation" : [
    {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v2-0078",
          "code" : "L",
          "display" : "Low"
        }
      ],
      "text" : "Below low normal"
    }
  ],
  "bodySite" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "code" : "308046002",
        "display" : "Superficial forearm vein"
      }
    ]
  },
  "method" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "code" : "120220003",
        "display" : "Injection to forearm"
      }
    ]
  },
  "derivedFrom" : [
    {
      🔗 "reference" : "Observation/example"
    }
  ],
  "component" : [
    //        Should have a refrange as well     
    {
      "code" : // 
           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
              
      {
        "coding" : [
          //       LOINC -code      
          {
            "system" : "http://loinc.org",
            "code" : "8480-6",
            "display" : "Systolic blood pressure"
          },
          {
            "system" : "http://snomed.info/sct",
            "code" : "271649006",
            "display" : "Systolic blood pressure"
          }
        ]
      },
      "valueQuantity" : //       SNOMED CT Codes      
      {
        "value" : 107,
        "unit" : "mmHg",
        "system" : "http://unitsofmeasure.org",
        "code" : "mm[Hg]"
      },
      "interpretation" : [
        //       an interpretation for the individual composite observation    
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/v2-0078",
              "code" : "N",
              "display" : "normal"
            }
          ],
          "text" : "Normal"
        }
      ]
    },
    {
      "code" : //       this codes only has a LOINC code      
      {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "8462-4",
            "display" : "Diastolic blood pressure"
          }
        ]
      },
      "valueQuantity" : {
        "value" : 60,
        "unit" : "mmHg",
        "system" : "http://unitsofmeasure.org",
        "code" : "mm[Hg]"
      },
      "interpretation" : [
        //       an interpretation for the individual composite observation    
        {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/v2-0078",
              "code" : "L",
              "display" : "low"
            }
          ],
          "text" : "Below low normal"
        }
      ]
    }
  ]
}