QI-Core Implementation Guide

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
Observation/example


<Observation xmlns="http://hl7.org/fhir">
  <id value="example"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: example</p><p><b>meta</b>: </p><p><b>status</b>: final</p><p><b>category</b>: Vital Signs <span style="background: LightGoldenRodYellow">(Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'vital-signs' = 'Vital Signs', given as 'Vital Signs'})</span></p><p><b>code</b>: Hemoglobin [Mass/volume] in Venous blood <span style="background: LightGoldenRodYellow">(Details : {LOINC code '30350-3' = 'Hemoglobin [Mass/volume] in Venous blood', given as 'Hemoglobin [Mass/volume] in Venous blood'})</span></p><p><b>subject</b>: <a href="Patient-example.html">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; </a></p><p><b>encounter</b>: <a href="Encounter-example.html">Generated Summary: id: example; status: in-progress; <span title="{http://terminology.hl7.org/CodeSystem/v3-ActCode IMP}">inpatient encounter</span>; <span title="Codes: {http://www.ama-assn.org/go/cpt 99223}">Inpatient Hospital Care</span></a></p><p><b>effective</b>: Apr 2, 2013 9:30:10 AM --&gt; Apr 5, 2013 9:30:10 AM</p><p><b>issued</b>: Apr 3, 2013 2:30:10 PM</p><p><b>value</b>: 7.2 g/dl<span style="background: LightGoldenRodYellow"> (Details: UCUM code g/dL = 'g/dL')</span></p><p><b>interpretation</b>: Below low normal <span style="background: LightGoldenRodYellow">(Details : {http://terminology.hl7.org/CodeSystem/v2-0078 code 'L' = 'Low', given as 'Low'})</span></p><p><b>bodySite</b>: Superficial forearm vein <span style="background: LightGoldenRodYellow">(Details : {SNOMED CT code '308046002' = 'Superficial forearm vein', given as 'Superficial forearm vein'})</span></p><p><b>method</b>: Injection to forearm <span style="background: LightGoldenRodYellow">(Details : {SNOMED CT code '120220003' = 'Injection to forearm', given as 'Injection to forearm'})</span></p><p><b>specimen</b>: <a href="Specimen-example.html">Generated Summary: id: example; <span title="Codes: {http://snomed.info/sct 122555007}">Venous blood specimen</span>; receivedTime: Mar 4, 2011 7:03:00 AM</a></p><p><b>derivedFrom</b>: <a href="Observation-example.html">Generated Summary: id: example; <span title="Codes: {http://terminology.hl7.org/CodeSystem/observation-category vital-signs}">Vital Signs</span>; <span title="Codes: {http://loinc.org 30350-3}">Hemoglobin [Mass/volume] in Venous blood</span>; effective: Apr 2, 2013 9:30:10 AM --&gt; Apr 5, 2013 9:30:10 AM; issued: Apr 3, 2013 2:30:10 PM; 7.2 g/dl; <span title="Codes: {http://terminology.hl7.org/CodeSystem/v2-0078 L}">Below low normal</span>; <span title="Codes: {http://snomed.info/sct 308046002}">Superficial forearm vein</span>; <span title="Codes: {http://snomed.info/sct 120220003}">Injection to forearm</span></a></p><blockquote><p><b>component</b></p><p><b>code</b>: Systolic blood pressure <span style="background: LightGoldenRodYellow">(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'})</span></p><p><b>value</b>: 107 mmHg<span style="background: LightGoldenRodYellow"> (Details: UCUM code mm[Hg] = 'mm[Hg]')</span></p><p><b>interpretation</b>: Normal <span style="background: LightGoldenRodYellow">(Details : {http://terminology.hl7.org/CodeSystem/v2-0078 code 'N' = 'Normal', given as 'normal'})</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: Diastolic blood pressure <span style="background: LightGoldenRodYellow">(Details : {LOINC code '8462-4' = 'Diastolic blood pressure', given as 'Diastolic blood pressure'})</span></p><p><b>value</b>: 60 mmHg<span style="background: LightGoldenRodYellow"> (Details: UCUM code mm[Hg] = 'mm[Hg]')</span></p><p><b>interpretation</b>: Below low normal <span style="background: LightGoldenRodYellow">(Details : {http://terminology.hl7.org/CodeSystem/v2-0078 code 'L' = 'Low', given as 'low'})</span></p></blockquote></div>
  </text>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/observation-bodyPosition">
    <valueCodeableConcept>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="33586001"/>
        <display value="Sitting position (finding)"/>
      </coding>
    </valueCodeableConcept>
  </extension>
  <extension url="http://hl7.org/fhir/StructureDefinition/observation-delta">
    <valueCodeableConcept>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="1250004"/>
        <display value="Decreased (qualifier value)"/>
      </coding>
    </valueCodeableConcept>
  </extension>
  <status value="final"/>
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
      <code value="vital-signs"/>
      <display value="Vital Signs"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://loinc.org"/>
      <code value="30350-3"/>
      <display value="Hemoglobin [Mass/volume] in Venous blood"/>
    </coding>
  </code>
  <subject>
    <reference value="Patient/example"/>
  </subject>
  <encounter>
    <reference value="Encounter/example"/>
  </encounter>
  <effectivePeriod>
    <start value="2013-04-02T10:30:10+01:00"/>
    <end value="2013-04-05T10:30:10+01:00"/>
  </effectivePeriod>
  <issued value="2013-04-03T15:30:10+01:00"/>
  <valueQuantity>
    <value value="7.2"/>
    <unit value="g/dl"/>
    <system value="http://unitsofmeasure.org"/>
    <code value="g/dL"/>
  </valueQuantity>
  <interpretation>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v2-0078"/>
      <code value="L"/>
      <display value="Low"/>
    </coding>
    <text value="Below low normal"/>
  </interpretation>
  <bodySite>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="308046002"/>
      <display value="Superficial forearm vein"/>
    </coding>
  </bodySite>
  <method>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="120220003"/>
      <display value="Injection to forearm"/>
    </coding>
  </method>
  <specimen>
    <reference value="Specimen/example"/>
  </specimen>
  <derivedFrom>
    <reference value="Observation/example"/>
  </derivedFrom>
<!--        Should have a refrange as well      -->
  <component>
  <!-- 
           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
               -->
    <code>
    <!--       LOINC -code       -->
      <coding>
        <system value="http://loinc.org"/>
        <code value="8480-6"/>
        <display value="Systolic blood pressure"/>
      </coding>
    <!--       SNOMED CT Codes       -->
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="271649006"/>
        <display value="Systolic blood pressure"/>
      </coding>
    <!--       Also, a local code specific to the source system       -->
      <coding>
        <system value="http://acme.org/devices/clinical-codes"/>
        <code value="bp-s"/>
        <display value="Systolic Blood pressure"/>
      </coding>
    </code>
    <valueQuantity>
      <value value="107"/>
      <unit value="mmHg"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm[Hg]"/>
    </valueQuantity>
  <!--       an interpretation for the individual composite observation     -->
    <interpretation>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0078"/>
        <code value="N"/>
        <display value="normal"/>
      </coding>
      <text value="Normal"/>
    </interpretation>
  </component>
<!--        Should have a refrange as well      -->
  <component>
  <!--       this codes only has a LOINC code       -->
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8462-4"/>
        <display value="Diastolic blood pressure"/>
      </coding>
    </code>
    <valueQuantity>
      <value value="60"/>
      <unit value="mmHg"/>
      <system value="http://unitsofmeasure.org"/>
      <code value="mm[Hg]"/>
    </valueQuantity>
  <!--       an interpretation for the individual composite observation     -->
    <interpretation>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0078"/>
        <code value="L"/>
        <display value="low"/>
      </coding>
      <text value="Below low normal"/>
    </interpretation>
  </component>
</Observation>