This page is part of the FHIR Specification (v4.1.0: Release 4B Ballot #1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2
Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Patient, Practitioner |
Raw XML (canonical form + also see XML Format Specification)
General Specimen Example (id = "101")
<?xml version="1.0" encoding="UTF-8"?> <Specimen xmlns="http://hl7.org/fhir"> <id value="101"/> <!-- text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml">[Put rendering here]</div> </text> --> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative</b> </p> <p> <b> identifier</b> : id: 23234352356</p> <p> <b> accessionIdentifier</b> : id: X352356</p> <p> <b> status</b> : available</p> <p> <b> type</b> : <span> Venous blood specimen</span> </p> <p> <b> subject</b> : <a> Peter Patient. Generated Summary: Medical record number: 12345 (USUAL); active; Peter James Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); , Phone: (03) 5555 6473, Phone: (03) 3410 5613, Phone: (03) 5555 8834; gender: male; birthDate: 1974-12-25; </a> </p> <p> <b> receivedTime</b> : 4 Mar. 2011, 6:03:00 pm</p> <p> <b> request</b> : <a> Generated Summary: status: completed; intent: order; <span> Diagnostics Procedure</span> ; <span> Computed tomography of head</span> </a> </p> <h3> Collections</h3> <table> <tr> <td> -</td> <td> <b> Collector</b> </td> <td> <b> Collected[x]</b> </td> <td> <b> Quantity</b> </td> <td> <b> Method</b> </td> <td> <b> BodySite</b> </td> </tr> <tr> <td> *</td> <td> <a> Generated Summary: id: 23; active; Adam Careful </a> </td> <td> 30 May 2011, 4:15:00 pm</td> <td> 6 mL</td> <td> <span> Line, Venous</span> </td> <td> <span> Right median cubital vein</span> </td> </tr> </table> <h3> Containers</h3> <table> <tr> <td> -</td> <td> <b> Identifier</b> </td> <td> <b> Description</b> </td> <td> <b> Type</b> </td> <td> <b> Capacity</b> </td> <td> <b> SpecimenQuantity</b> </td> <td> <b> Additive[x]</b> </td> </tr> <tr> <td> *</td> <td> id: 48736-15394-75465</td> <td> Green Gel tube</td> <td> <span> Vacutainer</span> </td> <td> 10 mL</td> <td> 6 mL</td> <td> <a> </a> <blockquote> <p> <b> instance</b> : false</p> <h3> Codes</h3> <table> <tr> <td> -</td> </tr> <tr> <td> *</td> </tr> </table> </blockquote> </td> </tr> </table> <p> <b> note</b> : Specimen is grossly lipemic</p> </div> </text> <contained> <Substance> <id value="hep"/> <instance value="false"/> <code> <concept> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-EntityCode"/> <code value="HEPL"/> </coding> </concept> </code> </Substance> </contained> <identifier> <!-- a specimen identifier - e.g. assigned when the specimen was taken this is often not done --> <system value="http://ehr.acme.org/identifiers/collections"/> <value value="23234352356"/> </identifier> <accessionIdentifier> <system value="http://lab.acme.org/specimens/2011"/> <value value="X352356"/> </accessionIdentifier> <status value="available"/> <type> <!-- Type is a loosely defined field because there is such a lot of variation in how it is used. The principal variation is how much information that could be represented elsewhere is also represented here. For instance, here's some possible types: lithium heparin plasma (+ .container.additive) (e.g. SNOMED CT 446272009) transfusion bag of blood (+ container.type) Peritoneal lavage (+ collection.bodySite) If the type includes other fields, it would be normal not to populate the other fields Note that this practice is so widespread that it's pointless to try and stop it --> <coding> <system value="http://snomed.info/sct"/> <code value="122555007"/> <display value="Venous blood specimen"/> </coding> </type> <subject> <reference value="Patient/example"/> <display value="Peter Patient"/> </subject> <receivedTime value="2011-03-04T07:03:00Z"/> <request> <!-- this points to the order that caused the sample to be drawn --> <reference value="ServiceRequest/example"/> </request> <collection> <collector> <!-- in practice, collecter is almost always recorded --> <reference value="Practitioner/example"/> </collector> <!-- the time of collection is usually required. Usually a point in time, but can be a period (collectedPeriod) if it's a timed collection (e.g. a 24 hour urine) --> <collectedDateTime value="2011-05-30T06:15:00Z"/> <quantity> <value value="6"/> <unit value="mL"/> <!-- e.g. full --> </quantity> <!-- method is usually implied by type --> <method> <coding> <system value="http://terminology.hl7.org/CodeSystem/v2-0488"/> <code value="LNV"/> </coding> </method> <!-- bodysite is usually implied by type too its here to demonstrate its usage to indicating the draw site in this case --> <bodySite> <coding> <system value="http://snomed.info/sct"/> <code value="49852007"/> <display value="Structure of median cubital vein (body structure)"/> </coding> <text value="Right median cubital vein"/> </bodySite> </collection> <!-- the container identifier is not the same as the specimen identifier usually, it is pre-printed/implanted etc.on the container prior to use. It might a RFID in the container, or it might be a UDI (http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/UniqueDeviceIdentification/) --> <container> <identifier> <!-- this is a serial number off the tube - there's no context such as a system --> <value value="48736-15394-75465"/> </identifier> <description value="Green Gel tube"/> <type> <!-- again, this might easily be used to cover additives and capacity as well --> <text value="Vacutainer"/> </type> <capacity> <value value="10"/> <unit value="mL"/> </capacity> <!-- if there's only one container, then this value is the same as .collection.quantity (usually). This is for when there is more than one container --> <specimenQuantity> <value value="6"/> <unit value="mL"/> </specimenQuantity> <additiveReference> <reference value="#hep"/> </additiveReference> </container> <note> <text value="Specimen is grossly lipemic"/> </note> </Specimen>
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.