Release 4

Observation-example.xml

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="http://hl7.org/fhir">
  <id value="example"/> 
  <!--     the mandatory quality flags:     -->
  <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : example</p> <p> <b> status</b> : final</p> <p> <b> category</b> : Vital Signs <span> (Details : {http://terminology.hl7.org/CodeSystem/observation-category code 'vital-signs'
           = 'Vital Signs', given as 'Vital Signs'})</span> </p> <p> <b> code</b> : Body Weight <span> (Details : {LOINC code '29463-7' = 'Body weight', given as 'Body Weight'}; {LOINC code
           '3141-9' = 'Body weight Measured', given as 'Body weight Measured'}; {SNOMED CT code '27113001'
           = 'Body weight', given as 'Body weight'}; {http://acme.org/devices/clinical-codes code
           'body-weight' = 'body-weight', given as 'Body Weight'})</span> </p> <p> <b> subject</b> : <a> Patient/example</a> </p> <p> <b> encounter</b> : <a> Encounter/example</a> </p> <p> <b> effective</b> : Mar 28, 2016</p> <p> <b> value</b> : 185 lbs<span>  (Details: UCUM code [lb_av] = 'lb_av')</span> </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.   -->
  <category> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/observation-category"/> 
      <code value="vital-signs"/> 
      <display value="Vital Signs"/> 
    </coding> 
  </category> 
  <!--    
    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
   LOINC
      - the source system provides its own code, which may be less or more granular than
   LOINC
      -->
  <code> 
    <!--     LOINC - always recommended to have a LOINC code     -->
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="29463-7"/>  <!--   more generic methodless LOINC   -->
      <display value="Body Weight"/> 
    </coding> 
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="3141-9"/> <!--   translation is more specific method = measured LOINC   -->
      <display value="Body weight Measured"/> 
    </coding> 
    <!--     SNOMED CT Codes - becoming more common     -->
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="27113001"/> 
      <display value="Body weight"/> 
    </coding> 
    <!--     Also, a local code specific to the source system     -->
    <coding> 
      <system value="http://acme.org/devices/clinical-codes"/> 
      <code value="body-weight"/> 
      <display value="Body Weight"/> 
    </coding> 
  </code> 
  <subject> 
    <reference value="Patient/example"/> 
  </subject> 
  <encounter> 
    <reference value="Encounter/example"/> 
  </encounter> 
  <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 (http://unitsofmeasure.org)
    is always preferred, but it doesn't provide notional units (such as
    "tablet"), etc. For these, something else is required (e.g. SNOMED CT)
       -->
  <valueQuantity> 
    <value value="185"/> 
    <unit value="lbs"/> 
    <system value="http://unitsofmeasure.org"/> 
    <code value="[lb_av]"/> 
  </valueQuantity> 
</Observation> 

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.