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| Orders and Observations Work Group | Maturity Level : N/A |
|
Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson |
Raw XML ( canonical form + also see XML Format Specification )
Blood Pressure Measurement cancelled (id = "blood-pressure-cancel")
<?xml version="1.0" encoding="UTF-8"?> <Observation xmlns="http://hl7.org/fhir"> <id value="blood-pressure-cancel"/> <meta> <profile value="http://hl7.org/fhir/StructureDefinition/vitalsigns"/><!-- EH Narrative created by build</meta> <!-- EH Narrative created by build <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">Sept 17, 2012: Systolic Blood pressure 107/60 mmHg (low)</div> </text>--> (Details : {http://hl7.org/fhir/observation-category code 'vital-signs' = 'Vital Signs', given as 'Vital Signs'})(Details : {LOINC code '85354-9' = 'lood pressure panel with all children optional', given as 'Bood pressure panel with all children optional'}): In this example, the blood pressure measurements are not available due to cancellation--><text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : blood-pressure-cancel</p> <p> <b> meta</b> : </p> <p> <b> identifier</b> : urn:uuid:187e0c12-8dd2-67e2-99b2-bf273c878281</p> <p> <b> status</b> : cancelled</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> : Blood pressure systolic & diastolic <span> (Details : {LOINC code '85354-9' = 'Blood pressure panel with all children optional', given as 'Blood pressure panel with all children optional'})</span> </p> <p> <b> subject</b> : <a> Patient/example</a> </p> <p> <b> effective</b> : 17/09/2012</p> <p> <b> performer</b> : <a> Practitioner/example</a> </p> <p> <b> interpretation</b> : Below low normal <span> (Details : {http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation code 'L' = 'Low', given as 'low'})</span> </p> <p> <b> note</b> : In this example, the blood pressure measurements are not available due to cancellation of the order. Data absent reason is present for each component</p> <p> <b> bodySite</b> : Right arm <span> (Details : {SNOMED CT code '368209003' = 'Right upper arm', given as 'Right arm'})</span> </p> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Systolic blood pressure <span> (Details : {LOINC code '8480-6' = 'Systolic blood pressure', given as 'Systolic blood pressure'}; {SNOMED CT code '271649006' = 'Systolic blood pressure', given as 'Systolic blood pressure'}; {http://acme.org/devices/clinical-codes code 'bp-s' = 'bp-s', givenas 'Systolic Blood pressure'})(Details : {http://hl7.org/fhir/data-absent-reason code 'not-asked' = 'Not Asked', given as 'Not Asked'})(Details : {LOINC code '8462-4' = 'Diastolic blood pressure', given as 'Diastolic blood pressure'})(Details : {http://hl7.org/fhir/data-absent-reason code 'not-asked' = 'Not Asked', given as 'Not Asked'})as 'Systolic Blood pressure'})</span> </p> <p> <b> dataAbsentReason</b> : Not Asked <span> (Details : {http://terminology.hl7.org/CodeSystem/data-absent-reason code 'not-asked' = 'Not Asked', given as 'Not Asked'})</span> </p> </blockquote> <blockquote> <p> <b> component</b> </p> <p> <b> code</b> : Diastolic blood pressure <span> (Details : {LOINC code '8462-4' = 'Diastolic blood pressure', given as 'Diastolic blood pressure'})</span> </p> <p> <b> dataAbsentReason</b> : Not Asked <span> (Details : {http://terminology.hl7.org/CodeSystem/data-absent-reason code 'not-asked' = 'Not Asked', given as 'Not Asked'})</span> </p> </blockquote> </div> </text> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:uuid:187e0c12-8dd2-67e2-99b2-bf273c878281"/> </identifier> <status value="cancelled"/> <category> <coding><system value="http://terminology.hl7.org/CodeSystem/observation-category"/> <code value="vital-signs"/> <display value="Vital Signs"/> </coding> </category><!-- replaced by 85354-9<code> <!-- replaced by 85354-9 <coding> <system value="http://loinc.org"/><code value="55284-4"/><code value="85354-9"/> <display value="Blood pressure systolic & diastolic"/> </coding>-->--><coding> <system value="http://loinc.org"/> <code value="85354-9"/><display value="Blood pressure panel with all children optional"/> </coding> <text value="Blood pressure systolic & diastolic"/> </code> <subject> <reference value="Patient/example"/> </subject> <effectiveDateTime value="2012-09-17"/> <performer> <reference value="Practitioner/example"/><!-- an interpretation offered to the combination observation</performer> <!-- an interpretation offered to the combination observation generally, it would only be appropriate to offer an interpretation of an observation that has no value if it has "COMP" (component)observations -->observations --><interpretation> <coding><system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/> <code value="L"/> <display value="low"/> </coding> <text value="Below low normal"/> </interpretation>In this example, the blood pressure measurements are not available due to cancellation of the order. Data absent reason is present for each component <!-- for an observation with components, these cannot disagree with the flags on the components --><note> <text value="In this example, the blood pressure measurements are not available due to cancellation of the order. Data absent reason is present for each component"/> </note> <!-- for an observation with components, these cannot disagree with the flags on the components --><bodySite> <coding> <system value="http://snomed.info/sct"/> <code value="368209003"/> <display value="Right arm"/> </coding> </bodySite><!--<component> <!-- Observations are often coded in multiple code systems. - LOINC provides a very specific code (though not usefully more specific in this particular case) - 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 LOINCthis instance shows the concept. The other codes only have a LOINC code -->this instance shows the concept. The other codes only have a LOINC code --><code> <!-- LOINC - always recommended to have a LOINC code --><coding> <system value="http://loinc.org"/> <code value="8480-6"/> <display value="Systolic blood pressure"/></coding> <!-- SNOMED CT Codes - becoming more common --><coding> <system value="http://snomed.info/sct"/> <code value="271649006"/> <display value="Systolic blood pressure"/></coding> <!-- Also, a local code specific to the source system --><coding> <system value="http://acme.org/devices/clinical-codes"/> <code value="bp-s"/> <display value="Systolic Blood pressure"/><!-- no value due to some error</coding> <!-- that shows the concept. The next two names only have a LOINC code --></code> <!-- no value due to some error <valueQuantity> <value value="107"/> <unit value="mm[Hg]"/> </valueQuantity>-->--><dataAbsentReason> <coding><system value="http://terminology.hl7.org/CodeSystem/data-absent-reason"/> <code value="not-asked"/> <display value="Not Asked"/> </coding> </dataAbsentReason> </component> <component> <code> <coding> <system value="http://loinc.org"/> <code value="8462-4"/> <display value="Diastolic blood pressure"/> </coding><!-- no value due to some error</code> <!-- no value due to some error <valueQuantity> <value value="60"/> <unit value="mm[Hg]"/> </valueQuantity>-->--><dataAbsentReason> <coding><system value="http://terminology.hl7.org/CodeSystem/data-absent-reason"/> <code value="not-asked"/> <display value="Not Asked"/> </coding> </dataAbsentReason> </component> </ 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.