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Diagnosticreport-example-f201-brainct.xml

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

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Real-world patient example (id = "f201")

<?xml version="1.0" encoding="UTF-8"?>

<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="f201"/> 
  <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : f201</p> <p> <b> status</b> : final</p> <p> <b> category</b> : Radiology <span> (Details : {SNOMED CT code '394914008' = 'Radiology - speciality', given as 'Radiology'};
           {http://terminology.hl7.org/CodeSystem/v2-0074 code 'RAD' = 'Radiology)</span> </p> <p> <b> code</b> : CT of head-neck <span> (Details : {SNOMED CT code '429858000' = 'Computed tomography (CT) of head and neck',
           given as 'Computed tomography (CT) of head and neck'})</span> </p> <p> <b> subject</b> : <a> Roel</a> </p> <p> <b> effective</b> : Dec 1, 2012 12:00:00 PM</p> <p> <b> issued</b> : Dec 1, 2012 12:00:00 PM</p> <p> <b> performer</b> : <a> Blijdorp MC</a> </p> <p> <b> imagingStudy</b> : HEAD and NECK CT DICOM imaging study</p> <p> <b> conclusion</b> : CT brains: large tumor sphenoid/clivus.</p> <p> <b> conclusionCode</b> : Malignant tumor of craniopharyngeal duct <span> (Details : {SNOMED CT code '188340000' = 'Malignant tumor of craniopharyngeal duct', given
           as 'Malignant tumor of craniopharyngeal duct'})</span> </p> </div> </text> <status value="final"/> <!--    No identifier or request details were available    --><category> <!--    The request was honored by the Department of Radiology    --><coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="394914008"/> 
      <display value="Radiology"/> 
    </coding> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/> 
      <code value="RAD"/> 
    </coding> 
  </category> 
  <code> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="429858000"/> 
      <display value="Computed tomography (CT) of head and neck"/> 
    </coding> 
    <text value="CT of head-neck"/> 
  </code> 
  <subject> 
    <reference value="Patient/f201"/> 
    <display value="Roel"/> 
  </subject> 
  <effectiveDateTime value="2012-12-01T12:00:00+01:00"/> 
  <issued value="2012-12-01T12:00:00+01:00"/> 
  <performer> 
    <reference value="Organization/f203"/> 
    <display value="Blijdorp MC"/> 
  </performer> <!--    The actual CT imagenot available -  following reference used to demonstrate the usage
   of the element   --><imagingStudy> 
    <display value="HEAD and NECK CT DICOM imaging study"/> 
  </imagingStudy> 
  <conclusion value="CT brains: large tumor sphenoid/clivus."/> 
  <conclusionCode> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="188340000"/> 
      <display value="Malignant tumor of craniopharyngeal duct"/> 
    </coding> 
  </conclusionCode> 
</DiagnosticReport> 

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.