Release 4B


Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner

Raw XML (canonical form + also see XML Format Specification)

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

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

<DiagnosticReport xmlns="">
  <id value="f201"/> 
  <text> <status value="generated"/> <div xmlns=""><h2> <span title="Codes: { 429858000}">CT of head-neck</span>  (<span title="Codes: { 394914008}, {
         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: { 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=""/> 
      <code value="394914008"/> 
      <display value="Radiology"/> 
      <system value=""/> 
      <code value="RAD"/> 
      <system value=""/> 
      <code value="429858000"/> 
      <display value="Computed tomography (CT) of head and neck"/> 
    <text value="CT of head-neck"/> 
    <reference value="Patient/f201"/> 
    <display value="Roel"/> 
  <effectiveDateTime value="2012-12-01T12:00:00+01:00"/> 
  <issued value="2012-12-01T12:00:00+01:00"/> 
    <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"/> 
  <conclusion value="CT brains: large tumor sphenoid/clivus."/> 
      <system value=""/> 
      <code value="188340000"/> 
      <display value="Malignant tumor of craniopharyngeal duct"/> 

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.