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Diagnosticreport-example-papsmear.xml

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

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

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An example of a principally narrative anatomic pathology report (id = "pap")

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

<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="pap"/> 
  <text> 
    <status value="additional"/> 
    <div xmlns="http://www.w3.org/1999/xhtml">
      <p> Acme Anatomic Pathology Services<br/>  2216 Santa Monica Blvd, Suite 114<br/>  Santa Monica, CA 90404<br/>  ===============================================================<br/>  GYN CYTOLOGY (PAP SMEAR) REPORT<br/>  ===============================================================</p> 
      <p> Patient: Everywoman, Eve Report Date: 2/14/2013<br/>  DOB: 05/31/1973 Age: 30 Sex: F MRN: PATID14567<br/>  Patient Address: 2222 Home Street<br/>   Huntington Park<br/>   CA 90255<br/>  Order: ORD40<br/>  Physician: Careful, Adam 5742200012 (NPI)<br/>  SpecimenID: GHSID40<br/>  Collected Date: 2/11/2013<br/>  Received Date: 2/12/2013<br/>  LMP: 1/28/2013<br/>  Specimen Source: Cervical Cytology (ThinPrep)<br/>  Previously abnormal Pap? Unknown</p> 
      <p> Specimen Adequacy: Satisfactory<br/>  Diagnostic Interpretation: Epithelial cell abnormality: Atypical squamous cells<br/>  of undetermined significance<br/>  Hormonal Evaluations: not possible, due to presence of atypical cells<br/>  Recommendations: Appropriate Follow-up. Suggest repeat as clinically indicated<br/>  Comments: Abnormal report reviewed by pathologist for confirmation</p> 
      <p/>  
    </div> 
  </text> 
  <status value="final"/> <!--      all this report is final      --><code> 
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="47527-7"/> 
    </coding> 
  </code> 
  <subject> 
    <reference value="Patient/b248b1b2-1686-4b94-9936-37d7a5f94b51"/> 
  </subject> 
  <effectiveDateTime value="2013-02-11T10:33:33+11:00"/> 
  <issued value="2013-02-13T11:45:33+11:00"/> 
  <performer> 
    <reference value="Practitioner/example"/> 
  </performer> 
</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.