Release 5 R6 Ballot (1st Draft)

This page is part of the FHIR Specification (v5.0.0: R5 - STU v6.0.0-ballot1: Release 6 Ballot (1st Draft) (see Ballot Notes ). This is the The current published version in it's permanent home (it will always be available at this URL). is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

Example Observation/example (XML)

Orders and Observations Work Group Maturity Level : N/A Standards Status : Informative Compartments : 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: Observation</b> <a name="example"> </a> </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 Observation &quot;example&quot; </p> </div> <p> <b> status</b> : <span title="   the mandatory quality flags:   ">final</span> </p> <p> <b> category</b> : <span title="  category code is A code that classifies the general type of observation being
         made. This is used for searching, sorting and display purposes.   
    Observations are often coded in multiple code systems.

         made. This is used for searching, sorting and display purposes. ">Vital Signs <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.4.0/CodeSystem-observation-category.html">Observation Category Codes</a> #vital-signs)</span> </span> </p> <p> <b> code</b> : <span title="  
    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

         codes as shown here

      - snomed provides a clinically relevant code that is usually less granular
         than LOINC

         than LOINC

      - the source system provides its own code, which may be less or more granular
         than LOINC
       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

         than LOINC
    ">Body Weight <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a> #29463-7; <a href="https://loinc.org/">LOINC</a> #3141-9 &quot;Body weight Measured&quot;; <a href="https://browser.ihtsdotools.org/">SNOMED CT</a> #27113001 &quot;Body weight&quot;; clinical-codes#body-weight)</span> </span> </p> <p> <b> subject</b> : <a href="patient-example.html">Patient/example</a>  &quot;Peter CHALMERS&quot;</p> <p> <b> encounter</b> : <a href="encounter-example.html">Encounter/example</a> </p> <p> <b> effective</b> : 2016-03-28</p> <p> <b> value</b> : <span title="   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

    &quot;tablet&quot;), etc. For these, something else is required (e.g. SNOMED
         CT)
     

         CT)
     ">185 lbs<span style="background: LightGoldenRodYellow"> (Details: UCUM code [lb_av] = 'lb_av')</span> </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.   -->
  
    
      
      
      
    
  
      <!--    
    Observations are often coded in multiple code systems.

   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

   codes as shown here

      - snomed provides a clinically relevant code that is usually less granular
   than LOINC

   than LOINC

      - the source system provides its own code, which may be less or more granular
   than LOINC
      -->
  
        
    
      
      
      
    
    
      
      
      
    
        
    
      
      
      
    
        
    
      
      
      
    
  
  
    
  
  
    
  
  
      <!--     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)
       -->
  
    
    
    
    
  

   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.