Release 5 Preview #3

Diagnosticreport-example-f001-bloodexam.json

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

Raw JSON (canonical form + also see JSON Format Specification)

Real-world patient example

{
  "resourceType": "Bundle",
  "id": "f001",
  "type": "collection",
  "entry": [
    {
      "fullUrl": "https://example.com/base/DiagnosticReport/f001",
      "resource": {
        "resourceType": "DiagnosticReport",
        "id": "f001",
        "text": {
          "status": "generated",
          "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>May 15, 2013 7:32:52 PM</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>Apr 2, 2013 9:30:10 AM --&gt; (ongoing)</td><td>Apr 3, 2013 3:30:10 PM</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>Apr 2, 2013 10:30:10 AM --&gt; Apr 5, 2013 10:30:10 AM</td><td>Apr 3, 2013 3:30:10 PM</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>Apr 2, 2013 10:30:10 AM --&gt; Apr 5, 2013 10:30:10 AM</td><td>Apr 3, 2013 3:30:10 PM</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>Apr 2, 2013 10:30:10 AM --&gt; Apr 5, 2013 10:30:10 AM</td><td>Apr 3, 2013 3:30:10 PM</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>Apr 5, 2013 10:30:10 AM --&gt; Apr 5, 2013 10:30:10 AM</td><td>Apr 5, 2013 3:30:10 PM</td></tr></table><p>Core lab</p></div>"
        },
        "identifier": [
          {
            "use": "official",
            "system": "http://www.bmc.nl/zorgportal/identifiers/reports",
            "value": "nr1239044"
          }
        ],
        "basedOn": [
          {
            "reference": "ServiceRequest/req"
          }
        ],
        "status": "final",
        "category": [
          {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "252275004",
                "display": "Haematology test"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
                "code": "HM"
              }
            ]
          }
        ],
        "code": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "58410-2",
              "display": "Complete blood count (hemogram) panel - Blood by Automated count"
            }
          ]
        },
        "subject": {
          "reference": "Patient/f001",
          "display": "P. van den Heuvel"
        },
        "issued": "2013-05-15T19:32:52+01:00",
        "performer": [
          {
            "reference": "Organization/f001",
            "display": "Burgers University Medical Centre"
          }
        ],
        "result": [
          {
            "reference": "Observation/f001"
          },
          {
            "reference": "Observation/f002"
          },
          {
            "reference": "Observation/f003"
          },
          {
            "reference": "Observation/f004"
          },
          {
            "reference": "Observation/f005"
          }
        ],
        "conclusion": "Core lab"
      }
    },
    {
      "fullUrl": "https://example.com/base/ServiceRequest/req",
      "resource": {
        "resourceType": "ServiceRequest",
        "id": "req",
        "text": {
          "status": "generated",
          "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>"
        },
        "extension": [
          {
            "url": "http://example.org/bodysitecode",
            "valueCodeableConcept": {
              "coding": [
                {
                  "system": "http://snomed.info/sct",
                  "code": "14975008",
                  "display": "Forearm structure"
                }
              ]
            }
          }
        ],
        "identifier": [
          {
            "system": "http://www.bmc.nl/zorgportal/identifiers/labresults",
            "value": "L2381"
          }
        ],
        "status": "active",
        "intent": "original-order",
        "code": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "58410-2",
              "display": "Complete blood count (hemogram) panel - Blood by Automated count"
            }
          ]
        },
        "subject": {
          "reference": "Patient/f001",
          "display": "P. van den Heuvel"
        },
        "encounter": {
          "reference": "Encounter/f001"
        },
        "requester": {
          "reference": "Practitioner/f001",
          "display": "E.van den Broek"
        },
        "note": [
          {
            "text": "patient almost fainted during procedure"
          }
        ]
      }
    }
  ]
}

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.