QI-Core Implementation Guide
8.0.0-ballot - STU 8 - ballot

QI-Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 8.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-qi-core/ and changes regularly. See the Directory of published versions

## : Observation example

Page standards status: Informative

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    @prefix fhir: <http://hl7.org/fhir/> .
    @prefix loinc: <https://loinc.org/rdf/> .
    @prefix owl: <http://www.w3.org/2002/07/owl#> .
    @prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
    @prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
    @prefix sct: <http://snomed.info/id/> .
    @prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

    # - resource -------------------------------------------------------------------

     a fhir:Observation ;
      fhir:nodeRole fhir:treeRoot ;
      fhir:id [ fhir:v "example"] ; #
      fhir:meta [
        ( fhir:profile [
    fhir:v "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-simple-observation"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-simple-observation>     ] )
      ] ; #
      fhir:language [ fhir:v "en"] ; #
      fhir:text [
    fhir:status [ fhir:v "extensions" ] ;
    fhir:div [ fhir:v "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en\" lang=\"en\"><p class=\"res-header-id\"><b>Generated Narrative: Observation example</b></p><a name=\"example\"> </a><a name=\"hcexample\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Language: en</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-qicore-simple-observation.html\">QICore Simple Observation</a></p></div><p><b>Observation Body Position</b>: <span title=\"Codes:{http://snomed.info/sct 33586001}\">Sitting position (finding)</span></p><p><b>status</b>: Final</p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/observation-category vital-signs}\">Vital Signs</span></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 30350-3}\">Hemoglobin [Mass/volume] in Venous blood</span></p><p><b>subject</b>: <a href=\"Patient-example.html\">Jim Chalmers  Male, DoB: 1974-12-25 ( Medical record number (use: usual, period: 2001-05-06 --&gt; (ongoing)))</a></p><p><b>encounter</b>: <a href=\"Encounter-example.html\">Encounter: status = in-progress; class = inpatient encounter (ActCode#IMP); type = Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.</a></p><p><b>effective</b>: 2013-04-02 10:30:10+0100 --&gt; 2013-04-05 10:30:10+0100</p><p><b>issued</b>: 2013-04-03 15:30:10+0100</p><p><b>performer</b>: <a href=\"Practitioner-example.html\">Practitioner</a></p><p><b>value</b>: 7.2 g/dl<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codeg/dL = 'g/dL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0078 L}\">Below low normal</span></p><p><b>bodySite</b>: <span title=\"Codes:{http://snomed.info/sct 308046002}\">Superficial forearm vein</span></p><p><b>method</b>: <span title=\"Codes:{http://snomed.info/sct 120220003}\">Injection to forearm</span></p><p><b>derivedFrom</b>: <a href=\"Observation-example.html\">Observation Hemoglobin [Mass/volume] in Venous blood</a></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 8480-6}, {http://snomed.info/sct 271649006}\">Systolic blood pressure</span></p><p><b>value</b>: 107 mmHg<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codemm[Hg] = 'mm[Hg]')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0078 N}\">Normal</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 8462-4}\">Diastolic blood pressure</span></p><p><b>value</b>: 60 mmHg<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM  codemm[Hg] = 'mm[Hg]')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v2-0078 L}\">Below low normal</span></p></blockquote></div>"^^rdf:XMLLiteral ]
      ] ; #
      fhir:extension ( [
    fhir:url [
    fhir:v "http://hl7.org/fhir/StructureDefinition/observation-bodyPosition"^^xsd:anyURI ;
    fhir:l <http://hl7.org/fhir/StructureDefinition/observation-bodyPosition>     ] ;
    fhir:value [
    a fhir:CodeableConcept ;
          ( fhir:coding [
    a sct:33586001 ;
    fhir:system [
    fhir:v "http://snomed.info/sct"^^xsd:anyURI ;
    fhir:l <http://snomed.info/sct>         ] ;
    fhir:code [ fhir:v "33586001" ] ;
    fhir:display [ fhir:v "Sitting position (finding)" ]       ] )     ]
      ] ) ; #
      fhir:status [ fhir:v "final"] ; #
      fhir:category ( [
        ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/observation-category"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/observation-category>       ] ;
    fhir:code [ fhir:v "vital-signs" ] ;
    fhir:display [ fhir:v "Vital Signs" ]     ] )
      ] ) ; #
      fhir:code [
        ( fhir:coding [
    a loinc:30350-3 ;
    fhir:system [
    fhir:v "http://loinc.org"^^xsd:anyURI ;
    fhir:l <http://loinc.org>       ] ;
    fhir:code [ fhir:v "30350-3" ] ;
    fhir:display [ fhir:v "Hemoglobin [Mass/volume] in Venous blood" ]     ] )
      ] ; #
      fhir:subject [
    fhir:l fhir:Patient/example ;
    fhir:reference [ fhir:v "Patient/example" ]
      ] ; #
      fhir:encounter [
    fhir:l fhir:Encounter/example ;
    fhir:reference [ fhir:v "Encounter/example" ]
      ] ; #
      fhir:effective [
    a fhir:Period ;
    fhir:start [ fhir:v "2013-04-02T10:30:10+01:00"^^xsd:dateTime ] ;
    fhir:end [ fhir:v "2013-04-05T10:30:10+01:00"^^xsd:dateTime ]
      ] ; #
      fhir:issued [ fhir:v "2013-04-03T15:30:10+01:00"^^xsd:dateTime] ; #
      fhir:performer ( [
    fhir:l fhir:Practitioner/example ;
    fhir:reference [ fhir:v "Practitioner/example" ] ;
    fhir:display [ fhir:v "Practitioner" ]
      ] ) ; #
      fhir:value [
    a fhir:Quantity ;
    fhir:value [ fhir:v 7.2 ] ;
    fhir:unit [ fhir:v "g/dl" ] ;
    fhir:system [
    fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ;
    fhir:l <http://unitsofmeasure.org>     ] ;
    fhir:code [ fhir:v "g/dL" ]
      ] ; #
      fhir:interpretation ( [
        ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/v2-0078"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/v2-0078>       ] ;
    fhir:code [ fhir:v "L" ] ;
    fhir:display [ fhir:v "Low" ]     ] ) ;
    fhir:text [ fhir:v "Below low normal" ]
      ] ) ; #
      fhir:bodySite [
        ( fhir:coding [
    a sct:308046002 ;
    fhir:system [
    fhir:v "http://snomed.info/sct"^^xsd:anyURI ;
    fhir:l <http://snomed.info/sct>       ] ;
    fhir:code [ fhir:v "308046002" ] ;
    fhir:display [ fhir:v "Superficial forearm vein" ]     ] )
      ] ; #
      fhir:method [
        ( fhir:coding [
    a sct:120220003 ;
    fhir:system [
    fhir:v "http://snomed.info/sct"^^xsd:anyURI ;
    fhir:l <http://snomed.info/sct>       ] ;
    fhir:code [ fhir:v "120220003" ] ;
    fhir:display [ fhir:v "Injection to forearm" ]     ] )
      ] ; #
      fhir:derivedFrom ( [
    fhir:l fhir:Observation/example ;
    fhir:reference [ fhir:v "Observation/example" ]
      ] ) ; #
      fhir:component ( [
    fhir:code [
          ( fhir:coding [
    a loinc:8480-6 ;
    fhir:system [
    fhir:v "http://loinc.org"^^xsd:anyURI ;
    fhir:l <http://loinc.org>         ] ;
    fhir:code [ fhir:v "8480-6" ] ;
    fhir:display [ fhir:v "Systolic blood pressure" ]       ] [
    a sct:271649006 ;
    fhir:system [
    fhir:v "http://snomed.info/sct"^^xsd:anyURI ;
    fhir:l <http://snomed.info/sct>         ] ;
    fhir:code [ fhir:v "271649006" ] ;
    fhir:display [ fhir:v "Systolic blood pressure" ]       ] ) #       LOINC -code           ] ; # \n           Observations are often coded in multiple code systems.\n           - LOINC provides a very specific code (though not more specific in this particular\n     case)\n           - snomed provides a clinically relevant code that is usually less granular\n     than LOINC\n           - the source system provides its own code, which may be less or more granular\n     than LOINC\n\nthis is shown here to demonstrate  the concept of translations within the codeableConcept\n     datatype. The diastolic code below only has a LOINC code\n
    fhir:value [
    a fhir:Quantity ;
    fhir:value [ fhir:v "107"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "mmHg" ] ;
    fhir:system [
    fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ;
    fhir:l <http://unitsofmeasure.org>       ] ;
    fhir:code [ fhir:v "mm[Hg]" ]     ] ;
        ( fhir:interpretation [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/v2-0078"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/v2-0078>         ] ;
    fhir:code [ fhir:v "N" ] ;
    fhir:display [ fhir:v "normal" ]       ] ) ;
    fhir:text [ fhir:v "Normal" ]     ] ) #       an interpretation for the individual composite observation
      ] [
    fhir:code [
          ( fhir:coding [
    a loinc:8462-4 ;
    fhir:system [
    fhir:v "http://loinc.org"^^xsd:anyURI ;
    fhir:l <http://loinc.org>         ] ;
    fhir:code [ fhir:v "8462-4" ] ;
    fhir:display [ fhir:v "Diastolic blood pressure" ]       ] )     ] ; #       this codes only has a LOINC code
    fhir:value [
    a fhir:Quantity ;
    fhir:value [ fhir:v "60"^^xsd:decimal ] ;
    fhir:unit [ fhir:v "mmHg" ] ;
    fhir:system [
    fhir:v "http://unitsofmeasure.org"^^xsd:anyURI ;
    fhir:l <http://unitsofmeasure.org>       ] ;
    fhir:code [ fhir:v "mm[Hg]" ]     ] ;
        ( fhir:interpretation [
          ( fhir:coding [
    fhir:system [
    fhir:v "http://terminology.hl7.org/CodeSystem/v2-0078"^^xsd:anyURI ;
    fhir:l <http://terminology.hl7.org/CodeSystem/v2-0078>         ] ;
    fhir:code [ fhir:v "L" ] ;
    fhir:display [ fhir:v "low" ]       ] ) ;
    fhir:text [ fhir:v "Below low normal" ]     ] ) #       an interpretation for the individual composite observation
      ] ) . #        Should have a refrange as well