This page is part of the FHIR Specification (v4.6.0: R5 Draft Ballot). 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
Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner |
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Real-world patient example
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <http://loinc.org/rdf#> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix sct: <http://snomed.info/id/> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- <http://hl7.org/fhir/Bundle/f001> a fhir:Bundle; fhir:nodeRole fhir:treeRoot; fhir:Resource.id [ fhir:value "f001"]; fhir:Bundle.type [ fhir:value "collection"]; fhir:Bundle.entry [ fhir:index 0; fhir:Bundle.entry.fullUrl [ fhir:value "https://example.com/base/DiagnosticReport/f001" ]; fhir:Bundle.entry.resource <https://example.com/base/DiagnosticReport/f001> ], [ fhir:index 1; fhir:Bundle.entry.fullUrl [ fhir:value "https://example.com/base/ServiceRequest/req" ]; fhir:Bundle.entry.resource <https://example.com/base/ServiceRequest/req> ] . <https://example.com/base/DiagnosticReport/f001> a fhir:DiagnosticReport; fhir:Resource.id [ fhir:value "f001"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h2><span>Complete blood count (hemogram) panel - Blood by Automated count</span> (<span>Haematology test</span>) </h2><table><tr><td>Subject</td><td><b>Pieter van de Heuvel </b> 1944-11-17 ( id: 738472983 (USUAL))</td></tr><tr><td>Reported</td><td>16 May 2013, 4:32:52 am</td></tr><tr><td>Identifier:</td><td> id: nr1239044 (OFFICIAL)</td></tr></table><p><b>Report Details</b></p><table><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Reference Range</b></td><td><b>Flags</b></td><td><b>When For</b></td><td><b>Reported</b></td></tr><tr><td><a><span>Glucose [Moles/volume] in Blood</span></a></td><td>6.3 mmol/l</td><td>3.1 mmol/l - 6.2 mmol/l</td><td><span>High</span></td><td>2 Apr. 2013, 7:30:10 pm --> (ongoing)</td><td>4 Apr. 2013, 1:30:10 am</td></tr><tr><td><a><span>Base excess in Blood by calculation</span></a></td><td>12.6 mmol/l</td><td>7.1 mmol/l - 11.2 mmol/l</td><td><span>High</span></td><td>2 Apr. 2013, 8:30:10 pm --> 5 Apr. 2013, 8:30:10 pm</td><td>4 Apr. 2013, 1:30:10 am</td></tr><tr><td><a><span>Carbon dioxide in blood</span></a></td><td>6.2 kPa</td><td>4.8 kPa - 6.0 kPa</td><td><span>High</span></td><td>2 Apr. 2013, 8:30:10 pm --> 5 Apr. 2013, 8:30:10 pm</td><td>4 Apr. 2013, 1:30:10 am</td></tr><tr><td><a><span>Erythrocytes [#/volume] in Blood by Automated count</span></a></td><td>4.12 10^12/L</td><td> 12-14 y Male: 4.4 - 5.2 x 10^12/L ; 12-14 y Female: 4.2 - 4.8 x 10^12/L ; 15-17 y Male: 4.6 - 5.4 x 10^12/L ; 15-17 y Female: 4.2 - 4.8 x 10^12/L ; 18-64 y Male: 4.6 - 5.4 x 10^12/L ; 18-64 y Female: 4.0 - 4.8 x 10^12/L ; 65-74 y Male: 4.3 - 5.3 x 10^12/L ; 65-74 y Female: 4.1 - 4.9 x 10^12/L </td><td><span>Low</span></td><td>2 Apr. 2013, 8:30:10 pm --> 5 Apr. 2013, 8:30:10 pm</td><td>4 Apr. 2013, 1:30:10 am</td></tr><tr><td><a><span>Hemoglobin [Mass/volume] in Blood</span></a></td><td>7.2 g/dl</td><td>7.5 g/dl - 10 g/dl</td><td><span>Low</span></td><td>5 Apr. 2013, 8:30:10 pm --> 5 Apr. 2013, 8:30:10 pm</td><td>6 Apr. 2013, 1:30:10 am</td></tr></table><p>Core lab</p></div>" ]; fhir:DiagnosticReport.identifier [ fhir:index 0; fhir:Identifier.use [ fhir:value "official" ]; fhir:Identifier.system [ fhir:value "http://www.bmc.nl/zorgportal/identifiers/reports" ]; fhir:Identifier.value [ fhir:value "nr1239044" ] ]; fhir:DiagnosticReport.basedOn [ fhir:index 0; fhir:link <http://hl7.org/fhir/ServiceRequest/req>; fhir:Reference.reference [ fhir:value "ServiceRequest/req" ] ]; fhir:DiagnosticReport.status [ fhir:value "final"]; fhir:DiagnosticReport.category [ fhir:index 0; fhir:CodeableConcept.coding [ fhir:index 0; a sct:252275004; fhir:Coding.system [ fhir:value "http://snomed.info/sct" ]; fhir:Coding.code [ fhir:value "252275004" ]; fhir:Coding.display [ fhir:value "Haematology test" ] ], [ fhir:index 1; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0074" ]; fhir:Coding.code [ fhir:value "HM" ] ] ]; fhir:DiagnosticReport.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:58410-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "58410-2" ]; fhir:Coding.display [ fhir:value "Complete blood count (hemogram) panel - Blood by Automated count" ] ] ]; fhir:DiagnosticReport.subject [ fhir:link <http://hl7.org/fhir/Patient/f001>; fhir:Reference.reference [ fhir:value "Patient/f001" ]; fhir:Reference.display [ fhir:value "P. van den Heuvel" ] ]; fhir:DiagnosticReport.issued [ fhir:value "2013-05-15T19:32:52+01:00"^^xsd:dateTime]; fhir:DiagnosticReport.performer [ fhir:index 0; fhir:link <http://hl7.org/fhir/Organization/f001>; fhir:Reference.reference [ fhir:value "Organization/f001" ]; fhir:Reference.display [ fhir:value "Burgers University Medical Centre" ] ]; fhir:DiagnosticReport.result [ fhir:index 0; fhir:link <http://hl7.org/fhir/Observation/f001>; fhir:Reference.reference [ fhir:value "Observation/f001" ] ], [ fhir:index 1; fhir:link <http://hl7.org/fhir/Observation/f002>; fhir:Reference.reference [ fhir:value "Observation/f002" ] ], [ fhir:index 2; fhir:link <http://hl7.org/fhir/Observation/f003>; fhir:Reference.reference [ fhir:value "Observation/f003" ] ], [ fhir:index 3; fhir:link <http://hl7.org/fhir/Observation/f004>; fhir:Reference.reference [ fhir:value "Observation/f004" ] ], [ fhir:index 4; fhir:link <http://hl7.org/fhir/Observation/f005>; fhir:Reference.reference [ fhir:value "Observation/f005" ] ]; fhir:DiagnosticReport.conclusion [ fhir:value "Core lab"] . <http://hl7.org/fhir/ServiceRequest/req> a fhir:ServiceRequest . <http://hl7.org/fhir/Patient/f001> a fhir:Patient . <http://hl7.org/fhir/Organization/f001> a fhir:Organization . <http://hl7.org/fhir/Observation/f001> a fhir:Observation . <http://hl7.org/fhir/Observation/f002> a fhir:Observation . <http://hl7.org/fhir/Observation/f003> a fhir:Observation . <http://hl7.org/fhir/Observation/f004> a fhir:Observation . <http://hl7.org/fhir/Observation/f005> a fhir:Observation . <https://example.com/base/ServiceRequest/req> a fhir:ServiceRequest; fhir:Resource.id [ fhir:value "req"]; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ]; fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: L2381</p><p><b>status</b>: active</p><p><b>intent</b>: original-order</p><p><b>code</b>: <span>Complete blood count (hemogram) panel - Blood by Automated count</span></p><p><b>subject</b>: <a>P. van den Heuvel. Generated Summary: id: 738472983 (USUAL), id: ?ngen-9? (USUAL); active; Pieter van de Heuvel ; Phone: 0648352638, p.heuvel@gmail.com; gender: male; birthDate: 1944-11-17; <span>Getrouwd</span>; multipleBirth</a></p><p><b>encounter</b>: <a>Generated Summary: id: v1451 (OFFICIAL); status: completed; <span>ambulatory</span>; <span>Patient-initiated encounter</span>; <span>Non-urgent cardiological admission</span></a></p><p><b>requester</b>: <a>E.van den Broek. Generated Summary: id: 938273695 (OFFICIAL), id: 129IDH4OP733 (USUAL); Eric van den broek (OFFICIAL); Phone: 0205568263, E.M.vandenbroek@bmc.nl, Fax: 0205664440; gender: male; birthDate: 1975-12-07</a></p><p><b>note</b>: patient almost fainted during procedure</p></div>" ]; fhir:DomainResource.extension [ fhir:index 0; fhir:Extension.url [ fhir:value "http://example.org/bodysitecode" ]; fhir:Extension.valueCodeableConcept [ fhir:CodeableConcept.coding [ fhir:index 0; a sct:14975008; fhir:Coding.system [ fhir:value "http://snomed.info/sct" ]; fhir:Coding.code [ fhir:value "14975008" ]; fhir:Coding.display [ fhir:value "Forearm structure" ] ] ] ]; fhir:ServiceRequest.identifier [ fhir:index 0; fhir:Identifier.system [ fhir:value "http://www.bmc.nl/zorgportal/identifiers/labresults" ]; fhir:Identifier.value [ fhir:value "L2381" ] ]; fhir:ServiceRequest.status [ fhir:value "active"]; fhir:ServiceRequest.intent [ fhir:value "original-order"]; fhir:ServiceRequest.code [ fhir:CodeableConcept.coding [ fhir:index 0; a loinc:58410-2; fhir:Coding.system [ fhir:value "http://loinc.org" ]; fhir:Coding.code [ fhir:value "58410-2" ]; fhir:Coding.display [ fhir:value "Complete blood count (hemogram) panel - Blood by Automated count" ] ] ]; fhir:ServiceRequest.subject [ fhir:link <http://hl7.org/fhir/Patient/f001>; fhir:Reference.reference [ fhir:value "Patient/f001" ]; fhir:Reference.display [ fhir:value "P. van den Heuvel" ] ]; fhir:ServiceRequest.encounter [ fhir:link <http://hl7.org/fhir/Encounter/f001>; fhir:Reference.reference [ fhir:value "Encounter/f001" ] ]; fhir:ServiceRequest.requester [ fhir:link <http://hl7.org/fhir/Practitioner/f001>; fhir:Reference.reference [ fhir:value "Practitioner/f001" ]; fhir:Reference.display [ fhir:value "E.van den Broek" ] ]; fhir:ServiceRequest.note [ fhir:index 0; fhir:Annotation.text [ fhir:value "patient almost fainted during procedure" ] ] . <http://hl7.org/fhir/Encounter/f001> a fhir:Encounter . <http://hl7.org/fhir/Practitioner/f001> a fhir:Practitioner . # - ontology header ------------------------------------------------------------ <http://hl7.org/fhir/Bundle/f001.ttl> a owl:Ontology; owl:imports fhir:fhir.ttl; owl:versionIRI <http://build.fhir.org/Bundle/f001.ttl> . # -------------------------------------------------------------------------------------
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.