Release 5 Draft Ballot

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Diagnosticreport-example-f001-bloodexam.xml

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

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

Real-world patient example (id = "f001")

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

<Bundle xmlns="http://hl7.org/fhir">
  <id value="f001"/> 
  <type value="collection"/> 
  <entry> 
    <fullUrl value="https://example.com/base/DiagnosticReport/f001"/> 
    <resource> 
      <DiagnosticReport> <!--     ISO 8601     --><!--     OID: 2.16.840.1.113883.4.642.1.7     --><id value="f001"/> 
        <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><h2> <span title="Codes: {http://loinc.org 58410-2}">Complete blood count (hemogram) 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> <b> Pieter van de Heuvel </b>  (no stated gender) 1944-11-17 ( id: 738472983 (USUAL))</td> </tr> <tr> <td> Reported</td> <td> 2013-05-15T19:32:52+01:00</td> </tr> <tr> <td> Identifier:</td> <td>  id: nr1239044 (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-f001.html"><span title="Codes: {http://loinc.org 15074-8}">Glucose [Moles/volume] in Blood</span> </a> </td> <td> 6.3 mmol/l</td> <td> 3.1 mmol/l - 6.2 mmol/l</td> <td> <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}">High</span> </td> <td> 2013-04-02T09:30:10+01:00 --&gt; (ongoing)</td> <td> 2013-04-03T15:30:10+01:00</td> </tr> <tr> <td> <a href="observation-f002.html"><span title="Codes: {http://loinc.org 11555-0}">Base excess in Blood by calculation</span> </a> </td> <td> 12.6 mmol/l</td> <td> 7.1 mmol/l - 11.2 mmol/l</td> <td> <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}">High</span> </td> <td> 2013-04-02T10:30:10+01:00 --&gt; 2013-04-05T10:30:10+01:00</td> <td> 2013-04-03T15:30:10+01:00</td> </tr> <tr> <td> <a href="observation-f003.html"><span title="Codes: {http://loinc.org 11557-6}">Carbon dioxide in blood</span> </a> </td> <td> 6.2 kPa</td> <td> 4.8 kPa - 6.0 kPa</td> <td> <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}">High</span> </td> <td> 2013-04-02T10:30:10+01:00 --&gt; 2013-04-05T10:30:10+01:00</td> <td> 2013-04-03T15:30:10+01:00</td> </tr> <tr> <td> <a href="observation-f004.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</td> <td>  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       </td> <td> <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation L}">Low</span> </td> <td> 2013-04-02T10:30:10+01:00 --&gt; 2013-04-05T10:30:10+01:00</td> <td> 2013-04-03T15:30:10+01:00</td> </tr> <tr> <td> <a href="observation-f005.html"><span title="Codes: {http://loinc.org 718-7}">Hemoglobin [Mass/volume] in Blood</span> </a> </td> <td> 7.2 g/dl</td> <td> 7.5 g/dl - 10 g/dl</td> <td> <span title="Codes: {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation L}">Low</span> </td> <td> 2013-04-05T10:30:10+01:00 --&gt; 2013-04-05T10:30:10+01:00</td> <td> 2013-04-05T15:30:10+01:00</td> </tr> </table> <p> Core lab</p> </div> </text> <identifier> 
          <use value="official"/> 
          <system value="http://www.bmc.nl/zorgportal/identifiers/reports"/> 
          <value value="nr1239044"/> 
        </identifier> 
        <basedOn> 
          <reference value="ServiceRequest/req"/> 
        </basedOn> 
        <status value="final"/> 
        <category> 
          <coding> 
            <system value="http://snomed.info/sct"/> 
            <code value="252275004"/> 
            <display value="Haematology test"/> 
          </coding> 
          <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/> 
            <code value="HM"/> 
          </coding> 
        </category> 
        <code> 
          <coding> 
            <system value="http://loinc.org"/> 
            <code value="58410-2"/> 
            <display value="Complete blood count (hemogram) panel - Blood by Automated count"/> 
          </coding> 
        </code> 
        <subject> 
          <reference value="Patient/f001"/> 
          <display value="P. van den Heuvel"/> 
        </subject> 
        <issued value="2013-05-15T19:32:52+01:00"/> 
        <performer> 
          <reference value="Organization/f001"/> 
          <display value="Burgers University Medical Centre"/> 
        </performer> 
        <result> 
          <reference value="Observation/f001"/> 
        </result> 
        <result> 
          <reference value="Observation/f002"/> 
        </result> 
        <result> 
          <reference value="Observation/f003"/> 
        </result> 
        <result> 
          <reference value="Observation/f004"/> 
        </result> 
        <result> 
          <reference value="Observation/f005"/> 
        </result> 
        <conclusion value="Core lab"/> 
      </DiagnosticReport> 
    </resource> 
  </entry> 
  <entry> 
    <fullUrl value="https://example.com/base/ServiceRequest/req"/> 
    <resource> 
      <ServiceRequest> 
        <id value="req"/> 
        <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative</b> </p> <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">Resource &quot;req&quot; </p> </div> <p> <b> identifier</b> : id: L2381</p> <p> <b> status</b> : active</p> <p> <b> intent</b> : original-order</p> <p> <b> code</b> : Complete blood count (hemogram) panel - Blood by Automated count <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a> #58410-2)</span> </p> <p> <b> subject</b> : <a href="patient-f001.html">Patient/f001: P. van den Heuvel</a>  &quot;Pieter VAN DE HEUVEL&quot;</p> <p> <b> encounter</b> : <a href="encounter-f001.html">Encounter/f001</a> </p> <p> <b> requester</b> : <a href="practitioner-f001.html">Practitioner/f001: E.van den Broek</a>  &quot;Eric VAN DEN BROEK&quot;</p> <p> <b> note</b> : patient almost fainted during procedure</p> </div> </text> <extension url="http://example.org/bodysitecode">
          <valueCodeableConcept> 
            <coding> 
              <system value="http://snomed.info/sct"/> 
              <code value="14975008"/> 
              <display value="Forearm structure"/> 
            </coding> 
          </valueCodeableConcept> 
        </extension> 
        <identifier> 
          <system value="http://www.bmc.nl/zorgportal/identifiers/labresults"/> 
          <value value="L2381"/> 
        </identifier> 
        <status value="active"/> 
        <intent value="original-order"/> 
        <code> 
          <coding> 
            <system value="http://loinc.org"/> 
            <code value="58410-2"/> 
            <display value="Complete blood count (hemogram) panel - Blood by Automated count"/> 
          </coding> 
        </code> 
        <subject> 
          <reference value="Patient/f001"/> 
          <display value="P. van den Heuvel"/> 
        </subject> 
        <encounter> 
          <reference value="Encounter/f001"/> 
        </encounter> 
        <requester> 
            <reference value="Practitioner/f001"/> 
            <display value="E.van den Broek"/> 
        </requester> 
        <note> 
          <text value="patient almost fainted during procedure"/> 
        </note> 
      </ServiceRequest> 
    </resource> 
  </entry> 
</Bundle> 

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.