QI-Core Implementation Guide: STU 4 (v4.0.0 for FHIR 4.0.1)

QI-Core Implementation Guide - This is the current published version.. See the Directory of published versions

Example: Observation-example

Formats: Narrative, XML, JSON, Turtle

Generated Narrative with Details

id: example

meta:

status: final

category: Vital Signs (Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'vital-signs' = 'Vital Signs', given as 'Vital Signs'})

code: Hemoglobin [Mass/volume] in Venous blood (Details : {LOINC code '30350-3' = 'Hemoglobin [Mass/volume] in Venous blood', given as 'Hemoglobin [Mass/volume] in Venous blood'})

subject: Generated Summary: id: example; Medical record number = 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim Chalmers , Peter James Windsor (MAIDEN); ph: (03) 5555 6473(WORK), ph: (03) 3410 5613(MOBILE), ph: (03) 5555 8834(OLD); gender: male; birthDate: 1974-12-25;

encounter: Generated Summary: id: example; status: in-progress; inpatient encounter; Inpatient Hospital Care

effective: Apr 2, 2013 9:30:10 AM --> Apr 5, 2013 9:30:10 AM

issued: Apr 3, 2013 2:30:10 PM

value: 7.2 g/dl (Details: UCUM code g/dL = 'g/dL')

interpretation: Below low normal (Details : {http://terminology.hl7.org/CodeSystem/v2-0078 code 'L' = 'Low', given as 'Low'})

bodySite: Superficial forearm vein (Details : {SNOMED CT code '308046002' = 'Superficial forearm vein', given as 'Superficial forearm vein'})

method: Injection to forearm (Details : {SNOMED CT code '120220003' = 'Injection to forearm', given as 'Injection to forearm'})

specimen: Generated Summary: id: example; Venous blood specimen; receivedTime: Mar 4, 2011 7:03:00 AM

derivedFrom: Generated Summary: id: example; Vital Signs; Hemoglobin [Mass/volume] in Venous blood; effective: Apr 2, 2013 9:30:10 AM --> Apr 5, 2013 9:30:10 AM; issued: Apr 3, 2013 2:30:10 PM; 7.2 g/dl; Below low normal; Superficial forearm vein; Injection to forearm

component

code: Systolic blood pressure (Details : {LOINC code '8480-6' = 'Systolic blood pressure', given as 'Systolic blood pressure'}; {SNOMED CT code '271649006' = 'Systolic blood pressure', given as 'Systolic blood pressure'}; {http://acme.org/devices/clinical-codes code 'bp-s' = 'bp-s', given as 'Systolic Blood pressure'})

value: 107 mmHg (Details: UCUM code mm[Hg] = 'mm[Hg]')

interpretation: Normal (Details : {http://terminology.hl7.org/CodeSystem/v2-0078 code 'N' = 'Normal', given as 'normal'})

component

code: Diastolic blood pressure (Details : {LOINC code '8462-4' = 'Diastolic blood pressure', given as 'Diastolic blood pressure'})

value: 60 mmHg (Details: UCUM code mm[Hg] = 'mm[Hg]')

interpretation: Below low normal (Details : {http://terminology.hl7.org/CodeSystem/v2-0078 code 'L' = 'Low', given as 'low'})