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Diagnosticreport-example-dxa.json

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: 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.