Release 5 Preview #3


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

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

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Simple Weight Example (id = "example")

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

<Observation xmlns="">
  <id value="example"/> 
  <!--     the mandatory quality flags:     -->
  <text> <status value="generated"/> <div xmlns=""><p> <b> Generated Narrative</b> </p> <p> <b> id</b> : example</p> <p/>  <p> <b> category</b> : <span> Vital Signs</span> </p> <p> <b> code</b> : <span> Body Weight</span> </p> <p> <b> subject</b> : <a> Generated Summary: id: example; Medical record number: 12345 (USUAL); active; Peter James
           Chalmers (OFFICIAL), Jim , Peter James Windsor (MAIDEN); -unknown-(HOME), ph: (03) 5555
           6473(WORK), ph: (03) 3410 5613(MOBILE), ph: (03) 5555 8834(OLD); gender: male; birthDate:
           1974-12-25; </a> </p> <p> <b> encounter</b> : <a> Generated Summary: id: example; status: in-progress; <span> inpatient encounter</span> </a> </p> <p> <b> effective</b> : 2016-03-28</p> <p> <b> value</b> : 185 lbs</p> </div> </text> <status value="final"/> 
  <!--    category code is A code that classifies the general type of observation being made.
   This is used for searching, sorting and display purposes.   -->
      <system value=""/> 
      <code value="vital-signs"/> 
      <display value="Vital Signs"/> 
    Observations are often coded in multiple code systems.
      - LOINC provides codes of varying granularity (though not usefully more specific
   in this particular case) and more generic LOINCs  can be mapped to more specific codes
   as shown here
      - snomed provides a clinically relevant code that is usually less granular than
      - the source system provides its own code, which may be less or more granular than
    <!--     LOINC - always recommended to have a LOINC code     -->
      <system value=""/> 
      <code value="29463-7"/>  <!--   more generic methodless LOINC   -->
      <display value="Body Weight"/> 
      <system value=""/> 
      <code value="3141-9"/> <!--   translation is more specific method = measured LOINC   -->
      <display value="Body weight Measured"/> 
    <!--     SNOMED CT Codes - becoming more common     -->
      <system value=""/> 
      <code value="27113001"/> 
      <display value="Body weight"/> 
    <!--     Also, a local code specific to the source system     -->
      <system value=""/> 
      <code value="body-weight"/> 
      <display value="Body Weight"/> 
    <reference value="Patient/example"/> 
    <reference value="Encounter/example"/> 
  <effectiveDateTime value="2016-03-28"/> 
  <!--     In FHIR, units may be represented twice. Once in the
    agreed human representation, and once in a coded form.
    Both is best, since it's not always possible to infer
    one from the other in code.

    When a computable unit is provided, UCUM (
    is always preferred, but it doesn't provide notional units (such as
    "tablet"), etc. For these, something else is required (e.g. SNOMED CT)
    <value value="185"/> 
    <unit value="lbs"/> 
    <system value=""/> 
    <code value="[lb_av]"/> 

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.