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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"><h2> <span> CT of head-neck</span>  (<span> Radiology</span> ) </h2> <table> <tr> <td> Subject</td> <td> <b> Roel(OFFICIAL)</b>   1960-03-13 ( BSN: 123456789 (OFFICIAL))</td> </tr> <tr> <td> When For</td> <td> Dec 1, 2012 12:00:00 PM</td> </tr> <tr> <td> Reported</td> <td> Dec 1, 2012 12:00:00 PM</td> </tr> </table> <p> <b> Report Details</b> </p> <p> CT brains: large tumor sphenoid/clivus.</p> <p> <b> Coded Conclusions :</b> </p> <ul> <li> <span> Malignant tumor of craniopharyngeal duct</span> </li> </ul> </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.