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Diagnosticreport-example-dxa.ttl

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner

Raw Turtle (+ also see Turtle/RDF Format Specification)

Imaging Example (Bone Density DXA)

@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/DiagnosticReport/102> a fhir:DiagnosticReport;
  fhir:nodeRole fhir:treeRoot;
  fhir:Resource.id [ fhir:value "102"];
  fhir:DomainResource.text [
     fhir:Narrative.status [ fhir:value "generated" ];
     fhir:Narrative.div "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n			<h2>DXA BONE DENSITOMETRY</h2>\n			<table>\n				<tr>\n					<td>NAME</td>\n					<td>XXXXXXX</td>\n				</tr>\n				<tr>\n					<td>DOB</td>\n					<td>10/02/1974</td>\n				</tr>\n				<tr>\n					<td>REFERRING DR</td>\n					<td>Smith, Jane</td>\n				</tr>\n				<tr>\n					<td>INDICATIONS</td>\n					<td>Early menopause on estrogen levels. No period  for 18 months</td>\n				</tr>\n				<tr>\n					<td>PROCEDURE</td>\n					<td>Dual energy x-ray absorptiometry (DEXA)</td>\n				</tr>\n			</table>\n			<h3>Bone Mineral Density</h3>\n			<table>\n				<tr>\n					<td>Scan Type</td>\n					<td>Region</td>\n					<td>Measured</td>\n					<td>Age</td>\n					<td>BMD</td>\n					<td>T-Score</td>\n					<td>Z-Score</td>\n					<td>?BMD(g/cm2)</td>\n					<td>?BMD(%)</td>\n				</tr>\n				<tr>\n					<td>AP Spine</td>\n					<td>L1-L4</td>\n					<td>17/06/2008</td>\n					<td>34.4</td>\n					<td>1.148 g/cm²</td>\n					<td>-0.4</td>\n					<td>-0.5</td>\n					<td>-</td>\n					<td>-</td>\n				</tr>\n				<tr>\n					<td>Left Femur</td>\n					<td>Neck</td>\n					<td>17/06/2008</td>\n					<td>34.4</td>\n					<td>0.891 g/cm²</td>\n					<td>-1.0</td>\n					<td>-0.9</td>\n					<td>-</td>\n					<td>-</td>\n				</tr>\n				<tr>\n					<td>Left Femur</td>\n					<td>Total</td>\n					<td>17/06/2008</td>\n					<td>34.4</td>\n					<td>0.887 g/cm²</td>\n					<td>-1.2</td>\n					<td>-1.3</td>\n					<td>-</td>\n					<td>-</td>\n				</tr>\n				<tr>\n					<td>Right Femur</td>\n					<td>Neck</td>\n					<td>17/06/2008</td>\n					<td>34.4</td>\n					<td>0.885 g/cm²</td>\n					<td>-1.0</td>\n					<td>-1.0</td>\n					<td>-</td>\n					<td>-</td>\n				</tr>\n				<tr>\n					<td>Right Femur</td>\n					<td>Total</td>\n					<td>17/06/2008</td>\n					<td>34.4</td>\n					<td>0.867 g/cm²</td>\n					<td>-1.4</td>\n					<td>-1.4</td>\n					<td>-</td>\n					<td>-</td>\n				</tr>\n			</table>\n			<p>Assessment:</p>\n			<ul>\n				<li>The Spine L1-L4 BMD is normal.</li>\n				<li>The Left Femur Neck BMD is in the osteopenic range. Relative fracture risk is about 2.</li>\n				<li>The Left Femur Total BMD is in the osteopenic range. Relative fracture risk is about 2.</li>\n				<li>The Right Femur Neck BMD is in the osteopenic range. Relative fracture risk is about 2.</li>\n				<li>The Right Femur Total BMD is in the osteopenic range. Relative fracture risk is about 2.</li>\n			</ul>\n			<p>\n				<b>COMMENT</b>\n			</p>\n			<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			<p>Thank you for your referral.  Dr Henry Seven  17/06/2008</p>\n			<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		</div>"
  ];
  fhir:DiagnosticReport.status [ fhir:value "final"];
  fhir:DiagnosticReport.code [
     fhir:CodeableConcept.coding [
       fhir:index 0;
       a loinc:38269-7;
       fhir:Coding.system [ fhir:value "http://loinc.org" ];
       fhir:Coding.code [ fhir:value "38269-7" ]
     ];
     fhir:CodeableConcept.text [ fhir:value "DXA BONE DENSITOMETRY" ]
  ];
  fhir:DiagnosticReport.subject [
     fhir:link <http://hl7.org/fhir/Patient/pat2>;
     fhir:Reference.reference [ fhir:value "Patient/pat2" ]
  ];
  fhir:DiagnosticReport.effectiveDateTime [ fhir:value "2008-06-17"^^xsd:date];
  fhir:DiagnosticReport.issued [ fhir:value "2008-06-18T09:23:00+10:00"^^xsd:dateTime];
  fhir:DiagnosticReport.performer [
     fhir:index 0;
     fhir:link <http://hl7.org/fhir/Practitioner/3ad0687e-f477-468c-afd5-fcc2bf897809>;
     fhir:Reference.reference [ fhir:value "Practitioner/3ad0687e-f477-468c-afd5-fcc2bf897809" ];
     fhir:Reference.display [ fhir:value "Dr Henry Seven" ]
  ];
  fhir:DiagnosticReport.result [
     fhir:index 0;
     fhir:link <http://hl7.org/fhir/Observation/bmd>;
     fhir:Reference.reference [ fhir:value "Observation/bmd" ]
  ];
  fhir:DiagnosticReport.conclusionCode [
     fhir:index 0;
     fhir:CodeableConcept.coding [
       fhir:index 0;
       a sct:391040000;
       fhir:Coding.system [ fhir:value "http://snomed.info/sct" ];
       fhir:Coding.code [ fhir:value "391040000" ];
       fhir:Coding.display [ fhir:value "At risk of osteoporotic fracture" ]
     ]
  ] .

<http://hl7.org/fhir/Patient/pat2> a fhir:Patient .

<http://hl7.org/fhir/Practitioner/3ad0687e-f477-468c-afd5-fcc2bf897809> a fhir:Practitioner .

<http://hl7.org/fhir/Observation/bmd> a fhir:Observation .

# - ontology header ------------------------------------------------------------

<http://hl7.org/fhir/DiagnosticReport/102.ttl> a owl:Ontology;
  owl:imports fhir:fhir.ttl;
  owl:versionIRI <http://build.fhir.org/DiagnosticReport/102.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.