Diagnosticreport-example-f201-brainct.xml

Real-world patient example (id = "f201")

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

<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="f201"/> 
  (Details : {SNOMED CT code '394914008' = 'Radiology - speciality', given as 'Radiology'};
           {http://terminology.hl7.org/CodeSystem/v2-0074 code 'RAD' = 'Radiology)(Details : {SNOMED CT code '429858000' = 'Computed tomography (CT) of head and neck',
           given as 'Computed tomography (CT) of head and neck'})(Details : {SNOMED CT code '188340000' = 'Malignant tumor of craniopharyngeal duct', given
           as 'Malignant tumor of craniopharyngeal duct'})

  <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><h2> <span title="Codes: {http://snomed.info/sct 429858000}">CT of head-neck</span>  (<span title="Codes: {http://snomed.info/sct 394914008}, {http://terminology.hl7.org/CodeSystem/v2-0074
         RAD}">Radiology</span> ) </h2> <table class="grid"><tr> <td> Subject</td> <td> <b> Roel(OFFICIAL)</b>  male, DoB: 1960-03-13 ( BSN: 123456789 (OFFICIAL))</td> </tr> <tr> <td> When For</td> <td> 2012-12-01T12:00:00+01:00</td> </tr> <tr> <td> Reported</td> <td> 2012-12-01T12:00:00+01:00</td> </tr> </table> <p> <b> Report Details</b> </p> <p> CT brains: large tumor sphenoid/clivus.</p> <p> <b> Coded Conclusions :</b> </p> <ul> <li> <span title="Codes: {http://snomed.info/sct 188340000}">Malignant tumor of craniopharyngeal duct</span> </li> </ul> </div> </text> <status value="final"/> <!--    No identifier or request details were available    --><category> <!--    The request was honored by the Department of Radiology    --><coding> 

      <system value="http://snomed.info/sct"/> 
      <code value="394914008"/> 
      <display value="Radiology"/> 
    </coding> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/> 
      <code value="RAD"/> 
    </coding> 
  </category> 
  <code> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="429858000"/> 
      <display value="Computed tomography (CT) of head and neck"/> 
    </coding> 
    <text value="CT of head-neck"/> 
  </code> 
  <subject> 
    
    

    <reference value="Patient/f201"/> 
    <display value="Roel"/> 
  </subject> 
  <effectiveDateTime value="2012-12-01T12:00:00+01:00"/> 
  <issued value="2012-12-01T12:00:00+01:00"/> 
  <performer> 
    
    

    <reference value="Organization/f203"/> 
    <display value="Blijdorp MC"/> 
  </performer> <!--    The actual CT imagenot available -  following reference used to demonstrate the usage
   of the element   --><imagingStudy> 
    

    <display value="HEAD and NECK CT DICOM imaging study"/> 
  </imagingStudy> 
  <conclusion value="CT brains: large tumor sphenoid/clivus."/> 
  <conclusionCode> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="188340000"/> 
      <display value="Malignant tumor of craniopharyngeal duct"/> 
    </coding> 
  </conclusionCode> 


</

DiagnosticReport

>