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Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner |
Raw JSON (canonical form + also see JSON Format Specification)
Imaging Example (Bone Density DXA)
{ "resourceType": "DiagnosticReport", "id": "102", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n\t\t\t<h2>DXA BONE DENSITOMETRY</h2>\n\t\t\t<table>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>NAME</td>\n\t\t\t\t\t<td>XXXXXXX</td>\n\t\t\t\t</tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>DOB</td>\n\t\t\t\t\t<td>10/02/1974</td>\n\t\t\t\t</tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>REFERRING DR</td>\n\t\t\t\t\t<td>Smith, Jane</td>\n\t\t\t\t</tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>INDICATIONS</td>\n\t\t\t\t\t<td>Early menopause on estrogen levels. No period for 18 months</td>\n\t\t\t\t</tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>PROCEDURE</td>\n\t\t\t\t\t<td>Dual energy x-ray absorptiometry (DEXA)</td>\n\t\t\t\t</tr>\n\t\t\t</table>\n\t\t\t<h3>Bone Mineral Density</h3>\n\t\t\t<table>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>Scan Type</td>\n\t\t\t\t\t<td>Region</td>\n\t\t\t\t\t<td>Measured</td>\n\t\t\t\t\t<td>Age</td>\n\t\t\t\t\t<td>BMD</td>\n\t\t\t\t\t<td>T-Score</td>\n\t\t\t\t\t<td>Z-Score</td>\n\t\t\t\t\t<td>?BMD(g/cm2)</td>\n\t\t\t\t\t<td>?BMD(%)</td>\n\t\t\t\t</tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>AP Spine</td>\n\t\t\t\t\t<td>L1-L4</td>\n\t\t\t\t\t<td>17/06/2008</td>\n\t\t\t\t\t<td>34.4</td>\n\t\t\t\t\t<td>1.148 g/cm²</td>\n\t\t\t\t\t<td>-0.4</td>\n\t\t\t\t\t<td>-0.5</td>\n\t\t\t\t\t<td>-</td>\n\t\t\t\t\t<td>-</td>\n\t\t\t\t</tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>Left Femur</td>\n\t\t\t\t\t<td>Neck</td>\n\t\t\t\t\t<td>17/06/2008</td>\n\t\t\t\t\t<td>34.4</td>\n\t\t\t\t\t<td>0.891 g/cm²</td>\n\t\t\t\t\t<td>-1.0</td>\n\t\t\t\t\t<td>-0.9</td>\n\t\t\t\t\t<td>-</td>\n\t\t\t\t\t<td>-</td>\n\t\t\t\t</tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>Left Femur</td>\n\t\t\t\t\t<td>Total</td>\n\t\t\t\t\t<td>17/06/2008</td>\n\t\t\t\t\t<td>34.4</td>\n\t\t\t\t\t<td>0.887 g/cm²</td>\n\t\t\t\t\t<td>-1.2</td>\n\t\t\t\t\t<td>-1.3</td>\n\t\t\t\t\t<td>-</td>\n\t\t\t\t\t<td>-</td>\n\t\t\t\t</tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>Right Femur</td>\n\t\t\t\t\t<td>Neck</td>\n\t\t\t\t\t<td>17/06/2008</td>\n\t\t\t\t\t<td>34.4</td>\n\t\t\t\t\t<td>0.885 g/cm²</td>\n\t\t\t\t\t<td>-1.0</td>\n\t\t\t\t\t<td>-1.0</td>\n\t\t\t\t\t<td>-</td>\n\t\t\t\t\t<td>-</td>\n\t\t\t\t</tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>Right Femur</td>\n\t\t\t\t\t<td>Total</td>\n\t\t\t\t\t<td>17/06/2008</td>\n\t\t\t\t\t<td>34.4</td>\n\t\t\t\t\t<td>0.867 g/cm²</td>\n\t\t\t\t\t<td>-1.4</td>\n\t\t\t\t\t<td>-1.4</td>\n\t\t\t\t\t<td>-</td>\n\t\t\t\t\t<td>-</td>\n\t\t\t\t</tr>\n\t\t\t</table>\n\t\t\t<p>Assessment:</p>\n\t\t\t<ul>\n\t\t\t\t<li>The Spine L1-L4 BMD is normal.</li>\n\t\t\t\t<li>The Left Femur Neck BMD is in the osteopenic range. Relative fracture risk is about 2.</li>\n\t\t\t\t<li>The Left Femur Total BMD is in the osteopenic range. Relative fracture risk is about 2.</li>\n\t\t\t\t<li>The Right Femur Neck BMD is in the osteopenic range. Relative fracture risk is about 2.</li>\n\t\t\t\t<li>The Right Femur Total BMD is in the osteopenic range. Relative fracture risk is about 2.</li>\n\t\t\t</ul>\n\t\t\t<p>\n\t\t\t\t<b>COMMENT</b>\n\t\t\t</p>\n\t\t\t<p>Osteopenia on measured BMD. The estimated 10-year probability of fracture based on present age, gender and measured BMD is less than 10%. This absolute fracture risk remains low. A follow-up assessment may be considered in 2 to 3 years to monitor the trend in BMD.</p>\n\t\t\t<p>Thank you for your referral. Dr Henry Seven 17/06/2008</p>\n\t\t\t<pre>\nNote:\nWHO classification of osteoporosis (WHO Technical Report Series 1994: 843)\n- Normal: T-score equal to -1.0 s.d. or higher\n- Osteopenia: T-score between -1.0 and -2.5 s.d.\n- Osteoporosis: T-score equal to -2.5 s.d. or lower\n- Severe/Established osteoporosis: Osteoporosis with one or more fragility fracture.\nT-score: The number of s.d. from the mean BMD for a gender-matched young adult population.\nZ-score: The number of s.d. from the mean BMD for an age-, weight- and gender-matched population.\nReference for 10-year probability of fracture risk: Kanis JA, Johnell O, Oden A, Dawson A, De Laet C, Jonsson B. Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds. Osteoporos.Int. 2001;12(12):989-995.\nGE LUNAR PRODIGY DENSITOMETER\n</pre>\n\t\t</div>" }, "status": "final", "code": { "coding": [ { "system": "http://loinc.org", "code": "38269-7" } ], "text": "DXA BONE DENSITOMETRY" }, "subject": { "reference": "Patient/pat2" }, "effectiveDateTime": "2008-06-17", "issued": "2008-06-18T09:23:00+10:00", "performer": [ { "reference": "Practitioner/3ad0687e-f477-468c-afd5-fcc2bf897809", "display": "Dr Henry Seven" } ], "result": [ { "reference": "Observation/bmd" } ], "conclusionCode": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "391040000", "display": "At risk of osteoporotic fracture" } ] } ] }
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.