<Observation xmlns="http://hl7.org/fhir">
  <id value="FeedbackReferralStatusObservation Intance Example" />
  <meta>
    <profile value="http://hl7.org/fhir/us/bser/StructureDefinition/FeedbackReferralStatusObservation" />
  </meta>
  <status value="final" />
  <code>
    <coding>
      <system value="http://hl7.org/fhir/v3/NullFlavor" />
      <code value="UNC" />
      <display value="Feedback Referral Status Observation" />
    </coding>
  </code>
  <component>
    <ReferralActivityStatus>
      <code>
        <coding>
          <system value="http://hl7.org/fhir/v3/NullFlavor" />
          <code value="UNC" />
          <display value="Referral Activity Status" />
        </coding>
      </code>
      <valueCodeableConcept>
        <coding>
          <system value="http://hl7.org/fhir/v3/NullFlavor" />
          <code value="UNC" />
          <display value="Intake Completed" />
        </coding>
      </valueCodeableConcept>
    </ReferralActivityStatus>
  </component>
  <component>
    <ReferralActivityStatusReason>
      <code>
        <coding>
          <system value="http://hl7.org/fhir/v3/NullFlavor" />
          <code value="UNC" />
          <display value="Referral Activity Status Reason" />
        </coding>
      </code>
      <valueCodeableConcept>
        <coding>
          <system value="http://hl7.org/fhir/v3/NullFlavor" />
          <code value="UNC" />
          <display value="Patient met all intake requirements" />
        </coding>
      </valueCodeableConcept>
    </ReferralActivityStatusReason>
  </component>
  <component>
    <ReferralType>
      <code>
        <coding>
          <system value="http://hl7.org/fhir/v3/NullFlavor" />
          <code value="UNC" />
          <display value="Referral Type" />
        </coding>
      </code>
      <valueCodeableConcept>
        <coding>
          <system value="http://hl7.org/fhir/v3/NullFlavor" />
          <code value="UNC" />
          <display value="Arthritis" />
        </coding>
      </valueCodeableConcept>
    </ReferralType>
  </component>
  <component>
    <ReferralStatus>
      <code>
        <coding>
          <system value="http://hl7.org/fhir/v3/NullFlavor" />
          <code value="UNC" />
          <display value="Referral Status" />
        </coding>
      </code>
      <valueCodeableConcept>
        <coding>
          <system value="http://hl7.org/fhir/v3/NullFlavor" />
          <code value="UNC" />
          <display value="Active" />
        </coding>
      </valueCodeableConcept>
    </ReferralStatus>
  </component>
  <component>
    <ReferralIdentifier>
      <valueString>
        <value value="44552" />
      </valueString>
    </ReferralIdentifier>
  </component>
</Observation>