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Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner |
Raw JSON (canonical form + also see JSON Format Specification)
Real-world patient example
{ "resourceType" : "Bundle", "id" : "f001", "type" : "collection", "entry" : [{ "fullUrl" : "https://example.com/base/DiagnosticReport/f001", "resource" : { "resourceType" : "DiagnosticReport", "id" : "f001", "text" : { "status" : "generated", "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?\u00a0(use:\u00a0usual,\u00a0))</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\u00a0(use:\u00a0official,\u00a0)</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>" }, "identifier" : [{ "use" : "official", "system" : "http://www.bmc.nl/zorgportal/identifiers/reports", "value" : "nr1239044" }], "basedOn" : [{ "reference" : "ServiceRequest/req" }], "status" : "final", "category" : [{ "coding" : [{ "system" : "http://snomed.info/sct", "code" : "252275004", "display" : "Haematology test" }, { "system" : "http://terminology.hl7.org/CodeSystem/v2-0074", "code" : "HM" }] }], "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "58410-2", "display" : "CBC panel - Blood by Automated count" }] }, "subject" : { "reference" : "Patient/f001", "display" : "P. van den Heuvel" }, "issued" : "2013-05-15T19:32:52+01:00", "performer" : [{ "reference" : "Organization/f001", "display" : "Burgers University Medical Centre" }], "result" : [{ "reference" : "Observation/f001" }, { "reference" : "Observation/f002" }, { "reference" : "Observation/f003" }, { "reference" : "Observation/f004" }, { "reference" : "Observation/f005" }], "conclusion" : "Core lab" } }, { "fullUrl" : "https://example.com/base/ServiceRequest/req", "resource" : { "resourceType" : "ServiceRequest", "id" : "req", "text" : { "status" : "extensions", "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\u00a0(use:\u00a0official,\u00a0); 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>" }, "extension" : [{ "url" : "http://example.org/bodysitecode", "valueCodeableConcept" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "14975008", "display" : "Forearm structure" }] } }], "identifier" : [{ "system" : "http://www.bmc.nl/zorgportal/identifiers/labresults", "value" : "L2381" }], "status" : "active", "intent" : "original-order", "code" : { "concept" : { "coding" : [{ "system" : "http://loinc.org", "code" : "58410-2", "display" : "CBC panel - Blood by Automated count" }] } }, "subject" : { "reference" : "Patient/f001", "display" : "P. van den Heuvel" }, "encounter" : { "reference" : "Encounter/f001" }, "requester" : { "reference" : "Practitioner/f001", "display" : "E.van den Broek" }, "note" : [{ "text" : "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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