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Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner |
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Real-world patient example
@prefix fhir: <http://hl7.org/fhir/> . @prefix loinc: <https://loinc.org/rdf/> . @prefix owl: <http://www.w3.org/2002/07/owl#> . @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:Bundle ; fhir:nodeRole fhir:treeRoot ; fhir:id [ fhir:v "f001"] ; # fhir:type [ fhir:v "collection"] ; # fhir:entry ( [ fhir:fullUrl [ fhir:v "https://example.com/base/DiagnosticReport/f001"^^xsd:anyURI ] ; fhir:resource ( <https://example.com/base/DiagnosticReport/f001> ) ] [ fhir:fullUrl [ fhir:v "https://example.com/base/ServiceRequest/req"^^xsd:anyURI ] ; fhir:resource ( <https://example.com/base/ServiceRequest/req> ) ] )] . # <https://example.com/base/DiagnosticReport/f001> a fhir:DiagnosticReport ; fhir:id [ fhir:v "f001"] ; # ISO 8601 , OID: 2.16.840.1.113883.4.642.1.7 fhir:text [ fhir:status [ fhir:v "generated" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport f001</b></p><a name=\"f001\"> </a><a name=\"hcf001\"> </a><a name=\"f001-en-US\"> </a><h2><span title=\"Codes:{http://loinc.org 58410-2}\">CBC panel - Blood by Automated count</span> (<span title=\"Codes:{http://snomed.info/sct 252275004}, {http://terminology.hl7.org/CodeSystem/v2-0074 HM}\">Haematology test</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td>Pieter van de Heuvel male, DoB: 1944-11-17 ( urn:oid:2.16.840.1.113883.2.4.6.3#?ngen-9? (use: usual, ))</td></tr><tr><td>Reported</td><td>2013-05-15T19:32:52+01:00</td></tr><tr><td>Performer</td><td> <a href=\"organization-example-f001-burgers.html\">Burgers University Medical Centre</a></td></tr><tr><td>Identifier</td><td> <code>http://www.bmc.nl/zorgportal/identifiers/reports</code>/nr1239044 (use: official, )</td></tr></table><p><b>Report Details</b></p><table class=\"grid\"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Reference Range</b></td><td><b>Flags</b></td><td><b>When For</b></td><td><b>Reported</b></td></tr><tr><td><a href=\"observation-example-f001-glucose.html\"><span title=\"Codes:{http://loinc.org 15074-8}\">Glucose [Moles/volume] in Blood</span></a></td><td>6.3 mmol/l<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codemmol/L = 'mmol/L')</span></td><td>3.1 mmol/l<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codemmol/L = 'mmol/L')</span> - 6.2 mmol/l<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codemmol/L = 'mmol/L')</span></td><td>final, <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></td><td>2013-04-02T09:30:10+01:00</td><td>2013-04-03T15:30:10+01:00</td></tr><tr><td><a href=\"observation-example-f002-excess.html\"><span title=\"Codes:{http://loinc.org 11555-0}\">Base excess in Blood by calculation</span></a></td><td>12.6 mmol/l<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codemmol/L = 'mmol/L')</span></td><td>7.1 mmol/l<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codemmol/L = 'mmol/L')</span> - 11.2 mmol/l<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codemmol/L = 'mmol/L')</span></td><td>final, <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></td><td>2013-04-02T10:30:10+01:00</td><td>2013-04-03T15:30:10+01:00</td></tr><tr><td><a href=\"observation-example-f003-co2.html\"><span title=\"Codes:{http://loinc.org 11557-6}\">Carbon dioxide [Partial pressure] in Blood</span></a></td><td>6.2 kPa<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codekPa = 'kPa')</span></td><td>4.8 kPa<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codekPa = 'kPa')</span> - 6.0 kPa<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codekPa = 'kPa')</span></td><td>final, <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></td><td>2013-04-02T10:30:10+01:00</td><td>2013-04-03T15:30:10+01:00</td></tr><tr><td><a href=\"observation-example-f004-erythrocyte.html\"><span title=\"Codes:{http://loinc.org 789-8}\">Erythrocytes [#/volume] in Blood by Automated count</span></a></td><td>4.12 10^12/L<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code10*12/L = '10*12/L')</span></td><td><div><p>12-14 y Male: 4.4 - 5.2 x 10^12/L ; 12-14 y Female: 4.2 - 4.8 x 10^12/L ; 15-17 y Male: 4.6 - 5.4 x 10^12/L ; 15-17 y Female: 4.2 - 4.8 x 10^12/L ; 18-64 y Male: 4.6 - 5.4 x 10^12/L ; 18-64 y Female: 4.0 - 4.8 x 10^12/L ; 65-74 y Male: 4.3 - 5.3 x 10^12/L ; 65-74 y Female: 4.1 - 4.9 x 10^12/L</p>\n</div></td><td>final, <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation L}\">Low</span></td><td>2013-04-02T10:30:10+01:00</td><td>2013-04-03T15:30:10+01:00</td></tr><tr><td><a href=\"observation-example-f005-hemoglobin.html\"><span title=\"Codes:{http://loinc.org 718-7}\">Hemoglobin [Mass/volume] in Blood</span></a></td><td>7.2 g/dl<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codeg/dL = 'g/dL')</span></td><td>7.5 g/dl<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codeg/dL = 'g/dL')</span> - 10 g/dl<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codeg/dL = 'g/dL')</span></td><td>final, <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation L}\">Low</span></td><td>2013-04-05T10:30:10+01:00</td><td>2013-04-05T15:30:10+01:00</td></tr></table><div><p>Core lab</p>\n</div></div>" ] ; # fhir:identifier ( [ fhir:use [ fhir:v "official" ] ; fhir:system [ fhir:v "http://www.bmc.nl/zorgportal/identifiers/reports"^^xsd:anyURI ] ; fhir:value [ fhir:v "nr1239044" ] ] ) ; # fhir:basedOn ( [ fhir:reference [ fhir:v "ServiceRequest/req" ] ] ) ; # fhir:status [ fhir:v "final"] ; # fhir:category ( [ fhir:coding ( [ a sct:252275004 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ; fhir:code [ fhir:v "252275004" ] ; fhir:display [ fhir:v "Haematology test" ] ] [ fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v2-0074"^^xsd:anyURI ] ; fhir:code [ fhir:v "HM" ] ] ) ] ) ; # fhir:code [ fhir:coding ( [ a loinc:58410-2 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "58410-2" ] ; fhir:display [ fhir:v "CBC panel - Blood by Automated count" ] ] ) ] ; # fhir:subject [ fhir:reference [ fhir:v "Patient/f001" ] ; fhir:display [ fhir:v "P. van den Heuvel" ] ] ; # fhir:issued [ fhir:v "2013-05-15T19:32:52+01:00"^^xsd:dateTime] ; # fhir:performer ( [ fhir:reference [ fhir:v "Organization/f001" ] ; fhir:display [ fhir:v "Burgers University Medical Centre" ] ] ) ; # fhir:result ( [ fhir:reference [ fhir:v "Observation/f001" ] ] [ fhir:reference [ fhir:v "Observation/f002" ] ] [ fhir:reference [ fhir:v "Observation/f003" ] ] [ fhir:reference [ fhir:v "Observation/f004" ] ] [ fhir:reference [ fhir:v "Observation/f005" ] ] ) ; # fhir:conclusion [ fhir:v "Core lab"] . # <https://example.com/base/ServiceRequest/req> a fhir:ServiceRequest ; fhir:id [ fhir:v "req"] ; # fhir:text [ fhir:status [ fhir:v "extensions" ] ; fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ServiceRequest req</b></p><a name=\"req\"> </a><a name=\"hcreq\"> </a><a name=\"req-en-US\"> </a><p><b>org/bodysitecode</b>: <span title=\"Codes:{http://snomed.info/sct 14975008}\">Forearm structure</span></p><p><b>identifier</b>: <code>http://www.bmc.nl/zorgportal/identifiers/labresults</code>/L2381</p><p><b>status</b>: active</p><p><b>intent</b>: original-order</p><h3>Codes</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Concept</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://loinc.org 58410-2}\">CBC panel - Blood by Automated count</span></td></tr></table><p><b>subject</b>: <a href=\"patient-example-f001-pieter.html\">P. van den Heuvel</a></p><p><b>encounter</b>: <a href=\"encounter-example-f001-heart.html\">Encounter: identifier = http://www.amc.nl/zorgportal/identifiers/visits#v1451 (use: official, ); status = completed; class = ambulatory; priority = Non-urgent cardiological admission; type = Patient-initiated encounter</a></p><p><b>requester</b>: <a href=\"practitioner-example-f001-evdb.html\">E.van den Broek</a></p><p><b>note</b>: patient almost fainted during procedure</p></div>" ] ; # fhir:extension ( [ fhir:url [ fhir:v "http://example.org/bodysitecode"^^xsd:anyURI ] ; fhir:value [ a fhir:CodeableConcept ; fhir:coding ( [ a sct:14975008 ; fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ; fhir:code [ fhir:v "14975008" ] ; fhir:display [ fhir:v "Forearm structure" ] ] ) ] ] ) ; # fhir:identifier ( [ fhir:system [ fhir:v "http://www.bmc.nl/zorgportal/identifiers/labresults"^^xsd:anyURI ] ; fhir:value [ fhir:v "L2381" ] ] ) ; # fhir:status [ fhir:v "active"] ; # fhir:intent [ fhir:v "original-order"] ; # fhir:code [ fhir:concept [ fhir:coding ( [ a loinc:58410-2 ; fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ; fhir:code [ fhir:v "58410-2" ] ; fhir:display [ fhir:v "CBC panel - Blood by Automated count" ] ] ) ] ] ; # fhir:subject [ fhir:reference [ fhir:v "Patient/f001" ] ; fhir:display [ fhir:v "P. van den Heuvel" ] ] ; # fhir:encounter [ fhir:reference [ fhir:v "Encounter/f001" ] ] ; # fhir:requester [ fhir:reference [ fhir:v "Practitioner/f001" ] ; fhir:display [ fhir:v "E.van den Broek" ] ] ; # fhir:note ( [ fhir:text [ fhir:v "patient almost fainted during procedure" ] ] ) . # # -------------------------------------------------------------------------------------
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.
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