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Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner |
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Imaging Example (Bone Density DXA)
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <https://loinc.org/rdf/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> . @prefix xsd: <http://www.w3.org/2001/XMLSchema#> . # - resource ------------------------------------------------------------------- [a fhir:DiagnosticReport ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "102"] ; # fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir: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:status [ fhir:v "final"] ; # fhir:code [ fhir:coding ( [ a loinc:38269-7 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "38269-7" ] ] ) ; fhir:text [ fhir:v "DXA BONE DENSITOMETRY" ] ] ; # femur, laterality = left , first, various administrative/context stuff fhir:subject [ fhir:reference [ fhir:v "Patient/pat2" ] ] ; # fhir:effective [ fhir:v "2008-06-17"^^xsd:date] ; # fhir:issued [ fhir:v "2008-06-18T09:23:00+10:00"^^xsd:dateTime] ; # all this report is final fhir:performer ( [ fhir:reference [ fhir:v "Practitioner/3ad0687e-f477-468c-afd5-fcc2bf897809" ] ; fhir:display [ fhir:v "Dr Henry Seven" ] ] ) ; # well, actually. this isn't the patient, but it'll do for now fhir:result ( [ fhir:reference [ fhir:v "Observation/bmd" ] ] ) ; # but just one for now, but for this example there should be more as listed here #<reference value="Observation/bmd1"/> (LEFT 24701-5 DXA Femur [Mass/Area] Bone densityO g/cm2) #<reference value="Observation/bmd2> (LEFT 8263-0 Femur DXA [T-score] Bone densityO {T-score}) # #<reference value="Observation/bmd3"/> (RIGHT 24701-5 DXA Femur [Mass/Area] Bone densityO g/cm2) #<reference value="Observation/bmd4"/> (RIGHT 38263-0 Femur DXA [T-score] Bone densityO {T-score}) # #<reference value="Observation/bmd5"/> (24966-4 Lumbar spine DXA Bone densityO g/cm2) #<reference value="Observation/bmd6"/> (38267-1 Lumbar spine DXA [T-score] Bone densityO {T-score}) # fhir:conclusionCode ( [] )] . # the imaging service marks this to help find categories of patient # -------------------------------------------------------------------------------------
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.
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