DiagnosticReport Example: diagnosticreport-example-lipid-profile

Example XML

<?xml version="1.0" encoding="UTF-8"?>
<DiagnosticReport xmlns="http://hl7.org/fhir">
  <!-- Resource ID -->
  <id value="lipid-profile-example"/>

  <!-- Status - one of registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | unknown -->
  <status value="final"/>

  <!-- Category - Laboratory -->
  <category>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/v2-0074"/>
      <code value="LAB"/>
      <display value="Laboratory"/>
    </coding>
  </category>

  <!-- Code - Lipid Panel -->
  <code>
    <coding>
      <system value="http://loinc.org"/>
      <code value="24331-1"/>
      <display value="Lipid 1996 panel - Serum or Plasma"/>
    </coding>
  </code>

  <!-- Subject reference -->
  <subject>
    <reference value="#patient"/>
  </subject>

  <!-- Encounter reference (optional) -->
  <encounter>
    <reference value="#encounter"/>
  </encounter>

  <!-- Effective date/time of the report -->
  <effectiveDateTime value="2023-12-10T08:30:00+11:00"/>

  <!-- When the report was issued -->
  <issued value="2023-12-10T11:45:00+11:00"/>

  <!-- Who was responsible for the report -->
  <performer>
    <reference value="#organization"/>
  </performer>

  <!-- Specimen reference -->
  <specimen>
    <reference value="#specimen"/>
  </specimen>

  <!-- Results - references to the contained Observation resources -->
  <result>
    <reference value="#cholesterol"/>
  </result>
  <result>
    <reference value="#triglyceride"/>
  </result>
  <result>
    <reference value="#hdl"/>
  </result>
  <result>
    <reference value="#ldl"/>
  </result>

  <!-- Conclusion -->
  <conclusion value="Patient has elevated cholesterol and LDL levels with borderline HDL. Recommend lifestyle modifications and consideration of lipid-lowering therapy."/>

  <!-- Media - a graph of patient's lipid values over time -->
  <media>
    <comment value="Lipid trends over the past 12 months"/>
    <link>
      <contentType value="image/png"/>
      <url value="http://example.org/fhir/Binary/lipid-trend-graph"/>
    </link>
  </media>

  <!-- Contained resources -->
  <contained>
    <!-- Patient resource -->
    <Patient>
      <id value="patient"/>
      <identifier>
        <system value="http://example.org/fhir/identifier/mrn"/>
        <value value="12345"/>
      </identifier>
      <name>
        <family value="Smith"/>
        <given value="John"/>
      </name>
      <gender value="male"/>
      <birthDate value="1970-03-15"/>
    </Patient>

    <!-- Encounter resource -->
    <Encounter>
      <id value="encounter"/>
      <status value="finished"/>
      <class>
        <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
        <code value="AMB"/>
        <display value="ambulatory"/>
      </class>
      <type>
        <coding>
          <system value="http://snomed.info/sct"/>
          <code value="270427003"/>
          <display value="Patient-initiated encounter"/>
        </coding>
      </type>
      <subject>
        <reference value="#patient"/>
      </subject>
      <period>
        <start value="2023-12-10T07:15:00+11:00"/>
        <end value="2023-12-10T08:00:00+11:00"/>
      </period>
    </Encounter>

    <!-- Specimen resource -->
    <Specimen>
      <id value="specimen"/>
      <status value="available"/>
      <type>
        <coding>
          <system value="http://snomed.info/sct"/>
          <code value="119364003"/>
          <display value="Serum specimen"/>
        </coding>
      </type>
      <subject>
        <reference value="#patient"/>
      </subject>
      <receivedTime value="2023-12-10T07:45:00+11:00"/>
      <collection>
        <collectedDateTime value="2023-12-10T07:30:00+11:00"/>
        <fastingStatusCodeableConcept>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v2-0916"/>
            <code value="F"/>
            <display value="Patient fasting"/>
          </coding>
        </fastingStatusCodeableConcept>
      </collection>
    </Specimen>

    <!-- Organization resource -->
    <Organization>
      <id value="organization"/>
      <name value="Clinical Laboratories Inc."/>
      <telecom>
        <system value="phone"/>
        <value value="+1 (555) 123-4567"/>
      </telecom>
    </Organization>

    <!-- Cholesterol Observation resource - implementing the profile -->
    <Observation>
      <id value="cholesterol"/>
      <status value="final"/>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
          <code value="laboratory"/>
          <display value="Laboratory"/>
        </coding>
      </category>
      <!-- Code - using the fixed code from the profile -->
      <code>
        <coding>
          <system value="http://loinc.org"/>
          <code value="35200-5"/>
          <display value="Cholesterol [Mass or Moles/volume] in Serum or Plasma"/>
        </coding>
      </code>
      <subject>
        <reference value="#patient"/>
      </subject>
      <effectiveDateTime value="2023-12-10T08:30:00+11:00"/>
      <!-- Value - Cholesterol value in mmol/L as specified in the profile -->
      <valueQuantity>
        <value value="6.3"/>
        <unit value="mmol/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="mmol/L"/>
      </valueQuantity>
      <!-- Interpretation - High -->
      <interpretation>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
          <code value="H"/>
          <display value="High"/>
        </coding>
      </interpretation>
      <!-- Reference range - as fixed in the profile -->
      <referenceRange>
        <high>
          <value value="4.5"/>
          <unit value="mmol/L"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="mmol/L"/>
        </high>
        <text value="High Risk at or above 4.5 mmol/L (Per Australian NHF Recommendations)"/>
      </referenceRange>
    </Observation>

    <!-- Triglyceride Observation resource -->
    <Observation>
      <id value="triglyceride"/>
      <status value="final"/>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
          <code value="laboratory"/>
          <display value="Laboratory"/>
        </coding>
      </category>
      <code>
        <coding>
          <system value="http://loinc.org"/>
          <code value="35217-9"/>
          <display value="Triglyceride [Mass/volume] in Serum or Plasma"/>
        </coding>
      </code>
      <subject>
        <reference value="#patient"/>
      </subject>
      <effectiveDateTime value="2023-12-10T08:30:00+11:00"/>
      <valueQuantity>
        <value value="1.8"/>
        <unit value="mmol/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="mmol/L"/>
      </valueQuantity>
      <interpretation>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
          <code value="N"/>
          <display value="Normal"/>
        </coding>
      </interpretation>
      <referenceRange>
        <high>
          <value value="2.0"/>
          <unit value="mmol/L"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="mmol/L"/>
        </high>
        <text value="Normal range: less than 2.0 mmol/L"/>
      </referenceRange>
    </Observation>

    <!-- HDL Cholesterol Observation resource -->
    <Observation>
      <id value="hdl"/>
      <status value="final"/>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
          <code value="laboratory"/>
          <display value="Laboratory"/>
        </coding>
      </category>
      <code>
        <coding>
          <system value="http://loinc.org"/>
          <code value="2085-9"/>
          <display value="HDL Cholesterol [Mass/volume] in Serum or Plasma"/>
        </coding>
      </code>
      <subject>
        <reference value="#patient"/>
      </subject>
      <effectiveDateTime value="2023-12-10T08:30:00+11:00"/>
      <valueQuantity>
        <value value="0.9"/>
        <unit value="mmol/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="mmol/L"/>
      </valueQuantity>
      <interpretation>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
          <code value="L"/>
          <display value="Low"/>
        </coding>
      </interpretation>
      <referenceRange>
        <low>
          <value value="1.0"/>
          <unit value="mmol/L"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="mmol/L"/>
        </low>
        <text value="Desirable: greater than 1.0 mmol/L"/>
      </referenceRange>
    </Observation>

    <!-- LDL Cholesterol Observation resource -->
    <Observation>
      <id value="ldl"/>
      <status value="final"/>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/observation-category"/>
          <code value="laboratory"/>
          <display value="Laboratory"/>
        </coding>
      </category>
      <code>
        <coding>
          <system value="http://loinc.org"/>
          <code value="18262-6"/>
          <display value="LDL Cholesterol [Mass/volume] in Serum or Plasma"/>
        </coding>
      </code>
      <subject>
        <reference value="#patient"/>
      </subject>
      <effectiveDateTime value="2023-12-10T08:30:00+11:00"/>
      <valueQuantity>
        <value value="4.6"/>
        <unit value="mmol/L"/>
        <system value="http://unitsofmeasure.org"/>
        <code value="mmol/L"/>
      </valueQuantity>
      <interpretation>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"/>
          <code value="H"/>
          <display value="High"/>
        </coding>
      </interpretation>
      <referenceRange>
        <high>
          <value value="3.0"/>
          <unit value="mmol/L"/>
          <system value="http://unitsofmeasure.org"/>
          <code value="mmol/L"/>
        </high>
        <text value="Optimal: less than 3.0 mmol/L"/>
      </referenceRange>
    </Observation>
  </contained>
</DiagnosticReport>