DiagnosticReport Example: diagnosticreport-example-papsmear

Narrative

Acme Anatomic Pathology Services
2216 Santa Monica Blvd, Suite 114
Santa Monica, CA 90404
===============================================================
GYN CYTOLOGY (PAP SMEAR) REPORT
===============================================================

Patient: Everywoman, Eve Report Date: 2/14/2013
DOB: 05/31/1973 Age: 30 Sex: F MRN: PATID14567
Patient Address: 2222 Home Street
Huntington Park
CA 90255
Order: ORD40
Physician: Careful, Adam 5742200012 (NPI)
SpecimenID: GHSID40
Collected Date: 2/11/2013
Received Date: 2/12/2013
LMP: 1/28/2013
Specimen Source: Cervical Cytology (ThinPrep)
Previously abnormal Pap? Unknown

Specimen Adequacy: Satisfactory
Diagnostic Interpretation: Epithelial cell abnormality: Atypical squamous cells
of undetermined significance
Hormonal Evaluations: not possible, due to presence of atypical cells
Recommendations: Appropriate Follow-up. Suggest repeat as clinically indicated
Comments: Abnormal report reviewed by pathologist for confirmation

Example XML

<?xml version="1.0" encoding="UTF-8"?>
<DiagnosticReport xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
    <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></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>