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(v3.3.0:
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Ballot
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| Orders and Observations Work Group | Maturity Level : N/A | Ballot Status : Informative | Compartments : Device , Encounter , Patient , Practitioner |
An example of a principally narrative anatomic pathology report (id = "pap")
<DiagnosticReport xmlns="http://hl7.org/fhir"> <id value="pap"/> <text> <status value="additional"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p> Acme Anatomic Pathology Services<br/> 2216 Santa Monica Blvd, Suite 114<br/> Santa Monica, CA 90404<br/> ===============================================================<br/> GYN CYTOLOGY (PAP SMEAR) REPORT<br/> ===============================================================</p> <p> Patient: Everywoman, Eve Report Date: 2/14/2013<br/> DOB: 05/31/1973 Age: 30 Sex: F MRN: PATID14567<br/> Patient Address: 2222 Home Street<br/> Huntington Park<br/> CA 90255<br/> Order: ORD40<br/> Physician: Careful, Adam 5742200012 (NPI)<br/> SpecimenID: GHSID40<br/> Collected Date: 2/11/2013<br/> Received Date: 2/12/2013<br/> LMP: 1/28/2013<br/> Specimen Source: Cervical Cytology (ThinPrep)<br/> Previously abnormal Pap? Unknown</p> <p> Specimen Adequacy: Satisfactory<br/> Diagnostic Interpretation: Epithelial cell abnormality: Atypical squamous cells<br/> of undetermined significance<br/> Hormonal Evaluations: not possible, due to presence of atypical cells<br/> Recommendations: Appropriate Follow-up. Suggest repeat as clinically indicated<br/> Comments: Abnormal report reviewed by pathologist for confirmation</p> <p/> </div> </text><status value="final"/> <!-- all this report is final --><code> <coding> <system value="http://loinc.org"/> <code value="47527-7"/> </coding> </code> <subject> <reference value="Patient/b248b1b2-1686-4b94-9936-37d7a5f94b51"/> </subject> <effectiveDateTime value="2013-02-11T10:33:33+11:00"/> <issued value="2013-02-13T11:45:33+11:00"/> <performer><reference value="Practitioner/example"/> </performer> </ DiagnosticReport >
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.