PATH-R4-18a: Bundle Example - Urine Microscopy, Culture and Sensitivity Report (Unstructured)

path-mockup-MCS-01-report

  • This is an example of a complex report.
  • The results are represented using a single Observation and formatted as a blob of text.
  • The report includes a range of numeric, semi-quantitative and qualitative results.
  • In this example, the specimen (urine) was collected after the request was made. The specimen is linked to the request within the Bundle using Specimen.request.
  • A clinical interpretation/summary of the test results is carried in DiagnosticReport.conclusion.

The following is a simplified logical data model that illustrates the key references between the FHIR profiles in the example message bundle. To aid clarity, not all of the references are shown. For a detailed description of the relationships between the FHIR profiles, and how they may be used, refer to How to Construct a Pathology Test Report Bundle.


path-data-model-MCS-01-unstructured-report
<Bundle xmlns="http://hl7.org/fhir">
    <id value="Pathology-Bundle-Urine-MCS-01-Unstructured-Report-Example" />
    <meta>
        <lastUpdated value="2022-02-25T13:47:00+00:00" />
        <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Bundle" />
    </meta>
    <identifier>
        <system value="https://tools.ietf.org/html/rfc4122" />
        <value value="86834956-dc57-4b90-8f1b-6174a887ca27" />
    </identifier>
    <type value="message" />
    <entry>
        <fullUrl value="urn:uuid:f18a2226-c0ab-480d-b80a-b6561fe8f9c4" />
        <resource>
            <MessageHeader>
                <!--  TBC Review content of MessageHeader  -->
                <id value="f18a2226-c0ab-480d-b80a-b6561fe8f9c4" />
                <meta>
                    <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-MessageHeader" />
                </meta>
                <eventCoding>
                    <system value="http://snomed.info/sct" />
                    <code value="371528001" />
                    <display value="Pathology report" />
                </eventCoding>
                <destination>
                    <name value="PICKERING MEDICAL PRACTICE" />
                    <!--  TBC Update endpoint address  -->
                    <endpoint value="TBC" />
                    <!--  Requesting Organisation  -->
                    <receiver>
                        <reference value="urn:uuid:3c43b5b3-06d6-445f-ae9a-48d5f05df434" />
                    </receiver>
                </destination>
                <sender>
                    <!--  Performing Laboratory  -->
                    <reference value="urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338" />
                </sender>
                <source>
                    <!--  TBC Update endpoint address  -->
                    <endpoint value="TBC" />
                </source>
                <focus>
                    <!--  DiagnosticReport  -->
                    <reference value="urn:uuid:35d46ca1-f253-4c97-b7ee-fb5fccdf6c20" />
                </focus>
                <definition value="https://fhir.nhs.uk/England/MessageDefinition/England-Pathology-Report" />
            </MessageHeader>
        </resource>
    </entry>
    <entry>
        <fullUrl value="urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338" />
        <resource>
            <Organization>
                <!--  Performing Laboratory  -->
                <id value="8a6d85b8-9837-4fed-a257-4cf207988338" />
                <meta>
                    <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Organization" />
                </meta>
                <identifier>
                    <system value="https://fhir.nhs.uk/Id/ods-organization-code" />
                    <value value="Y8J7D" />
                </identifier>
                <name value="TD008362 PATH LAB 001" />
                <address>
                    <line value="PATHOLOGY LAB" />
                    <line value="7-8 WELLINGTON PLACE" />
                    <city value="LEEDS" />
                    <district value="WEST YORKSHIRE" />
                    <postalCode value="LS1 4AP" />
                </address>
            </Organization>
        </resource>
    </entry>
    <entry>
        <fullUrl value="urn:uuid:3c43b5b3-06d6-445f-ae9a-48d5f05df434" />
        <resource>
            <Organization>
                <!--  Requesting Organisation  -->
                <id value="3c43b5b3-06d6-445f-ae9a-48d5f05df434" />
                <meta>
                    <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Organization" />
                </meta>
                <identifier>
                    <system value="https://fhir.nhs.uk/Id/ods-organization-code" />
                    <value value="B82033" />
                </identifier>
                <name value="PICKERING MEDICAL PRACTICE" />
                <address>
                    <line value="SOUTHGATE" />
                    <city value="PICKERING" />
                    <district value="NORTH YORKSHIRE" />
                    <postalCode value="YO18 8BL" />
                </address>
            </Organization>
        </resource>
    </entry>
    <entry>
        <fullUrl value="urn:uuid:9a835acf-d715-4d84-8dcf-a8435f6417fe" />
        <resource>
            <Practitioner>
                <!--  Requesting Practitioner  -->
                <id value="9a835acf-d715-4d84-8dcf-a8435f6417fe" />
                <meta>
                    <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Practitioner" />
                </meta>
                <identifier>
                    <system value="https://fhir.hl7.org.uk/Id/gmc-number" />
                    <value value="C1008215" />
                </identifier>
                <name>
                    <use value="official" />
                    <family value="GASKELL" />
                    <given value="Gale" />
                    <prefix value="Dr" />
                </name>
            </Practitioner>
        </resource>
    </entry>
    <entry>
        <fullUrl value="urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4" />
        <resource>
            <Patient>
                <id value="ab87a3f8-1d37-44a9-804e-5e962598a6e4" />
                <meta>
                    <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Patient" />
                </meta>
                <identifier>
                    <extension url="https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-NHSNumberVerificationStatus">
                        <valueCodeableConcept>
                            <coding>
                                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-NHSNumberVerificationStatusEngland" />
                                <code value="01" />
                                <display value="Number present and verified" />
                            </coding>
                        </valueCodeableConcept>
                    </extension>
                    <system value="https://fhir.nhs.uk/Id/nhs-number" />
                    <value value="9727710859" />
                </identifier>
                <name>
                    <use value="official" />
                    <family value="MOXEY" />
                    <given value="Judy" />
                </name>
                <gender value="female" />
                <birthDate value="2004-05-06" />
                <address>
                    <line value="1 CASTLEGATE" />
                    <city value="PICKERING" />
                    <district value="NORTH YORKSHIRE" />
                    <postalCode value="YO18 7AY" />
                </address>
            </Patient>
        </resource>
    </entry>
    <entry>
        <fullUrl value="urn:uuid:1c38d507-9ad7-4b49-ba91-7da204842cac" />
        <resource>
            <ServiceRequest>
                <id value="1c38d507-9ad7-4b49-ba91-7da204842cac" />
                <meta>
                    <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-ServiceRequest-Lab" />
                </meta>
                <identifier>
                    <system value="http://B82033-pickeringmedicalpractice.com/labrequest" />
                    <value value="REQ-20220221-000018" />
                </identifier>
                <status value="active" />
                <intent value="order" />
                <code>
                    <coding>
                        <!--  From PaLM procedure reference set  -->
                        <system value="http://snomed.info/sct" />
                        <code value="401324008" />
                        <display value="Urinary microscopy, culture and sensitivities" />
                    </coding>
                </code>
                <subject>
                    <reference value="urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4" />
                    <display value="MOXEY, Judy" />
                </subject>
                <authoredOn value="2022-02-21T10:29:00+00:00" />
                <requester>
                    <reference value="urn:uuid:9a835acf-d715-4d84-8dcf-a8435f6417fe" />
                    <display value="GASKELL, Dr Gale" />
                </requester>
                <performer>
                    <reference value="urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338" />
                    <display value="TD008362 PATH LAB 001" />
                </performer>
            </ServiceRequest>
        </resource>
    </entry>
    <entry>
        <fullUrl value="urn:uuid:bde5b0a5-4fb3-4655-acf0-215b93aee006" />
        <resource>
            <Specimen>
                <id value="bde5b0a5-4fb3-4655-acf0-215b93aee006" />
                <meta>
                    <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Specimen" />
                </meta>
                <identifier>
                    <system value="http://B82033-pickeringmedicalpractice.com/specimen" />
                    <value value="SPC-REQ-20220221-000024" />
                </identifier>
                <accessionIdentifier>
                    <system value="http://Y8J7D-pathlab001.com/specimen" />
                    <value value="SPC-LAB-20220221-004306" />
                </accessionIdentifier>
                <status value="available" />
                <type>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="122575003" />
                        <display value="Urine specimen" />
                    </coding>
                </type>
                <subject>
                    <reference value="urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4" />
                    <display value="MOXEY, Judy" />
                </subject>
                <receivedTime value="2022-02-21T14:58:00+00:00" />
                <request>
                    <reference value="urn:uuid:1c38d507-9ad7-4b49-ba91-7da204842cac" />
                </request>
                <collection>
                    <collectedDateTime value="2022-02-21T11:07:00+00:00" />
                </collection>
            </Specimen>
        </resource>
    </entry>
    <entry>
        <fullUrl value="urn:uuid:35d46ca1-f253-4c97-b7ee-fb5fccdf6c20" />
        <resource>
            <DiagnosticReport>
                <id value="35d46ca1-f253-4c97-b7ee-fb5fccdf6c20" />
                <meta>
                    <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-DiagnosticReport-Lab" />
                </meta>
                <identifier>
                    <system value="http://Y8J7D-pathlab001.com/report" />
                    <value value="REP-20220225-006301" />
                </identifier>
                <basedOn>
                    <reference value="urn:uuid:1c38d507-9ad7-4b49-ba91-7da204842cac" />
                </basedOn>
                <status value="final" />
                <category>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/v2-0074" />
                        <code value="LAB" />
                        <display value="Laboratory" />
                    </coding>
                </category>
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="721981007" />
                        <display value="Diagnostic studies report" />
                    </coding>
                </code>
                <subject>
                    <reference value="urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4" />
                    <display value="MOXEY, Judy" />
                </subject>
                <issued value="2022-02-25T13:47:00+00:00" />
                <performer>
                    <reference value="urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338" />
                    <display value="TD008362 PATH LAB 001" />
                </performer>
                <specimen>
                    <reference value="urn:uuid:bde5b0a5-4fb3-4655-acf0-215b93aee006" />
                </specimen>
                <result>
                    <reference value="urn:uuid:bd867909-49ca-4a4b-b02f-162790b6800f" />
                </result>
                <conclusion value="Likely to be clinically significant." />
            </DiagnosticReport>
        </resource>
    </entry>
    <entry>
        <fullUrl value="urn:uuid:bd867909-49ca-4a4b-b02f-162790b6800f" />
        <resource>
            <Observation>
                <id value="bd867909-49ca-4a4b-b02f-162790b6800f" />
                <meta>
                    <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Observation-Lab" />
                </meta>
                <identifier>
                    <system value="https://tools.ietf.org/html/rfc4122" />
                    <value value="02875aea-9815-4d1d-b34e-f9f29b859d02" />
                </identifier>
                <status value="final" />
                <category>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/observation-category" />
                        <code value="laboratory" />
                        <display value="Laboratory" />
                    </coding>
                </category>
                <code>
                    <coding>
                        <!--  From PBCL observable entity reference set  -->
                        <system value="http://snomed.info/sct" />
                        <code value="995581000000104" />
                        <display value="Urinary microscopy, culture and sensitivities" />
                    </coding>
                </code>
                <subject>
                    <reference value="urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4" />
                    <display value="MOXEY, Judy" />
                </subject>
                <issued value="2022-02-25T13:47:00+00:00" />
                <performer>
                    <reference value="urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338" />
                    <display value="TD008362 PATH LAB 001" />
                </performer>
                <valueString value="Microscopy\nCasts  None seen\nWhite cells  &gt;35 x10*6/L\nRed cells  10-35 x10*6/L\nEpithelial cells  +\n\nCulture\n1. Staphylococcus aureus   Scanty growth\n\nSensitivities  1\nFlucloxacillin   S\nTrimethoprim  S\nNitrofurantoin  R" />
                <specimen>
                    <reference value="urn:uuid:bde5b0a5-4fb3-4655-acf0-215b93aee006" />
                </specimen>
            </Observation>
        </resource>
    </entry>
</Bundle>
{
    "resourceType": "Bundle",
    "id": "Pathology-Bundle-Urine-MCS-01-Unstructured-Report-Example",
    "meta": {
        "lastUpdated": "2022-02-25T13:47:00+00:00",
        "profile":  [
            "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Bundle"
        ]
    },
    "identifier": {
        "system": "https://tools.ietf.org/html/rfc4122",
        "value": "86834956-dc57-4b90-8f1b-6174a887ca27"
    },
    "type": "message",
    "entry":  [
        {
            "fullUrl": "urn:uuid:f18a2226-c0ab-480d-b80a-b6561fe8f9c4",
            "resource": {
                "resourceType": "MessageHeader",
                "id": "f18a2226-c0ab-480d-b80a-b6561fe8f9c4",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-MessageHeader"
                    ]
                },
                "eventCoding": {
                    "system": "http://snomed.info/sct",
                    "code": "371528001",
                    "display": "Pathology report"
                },
                "destination":  [
                    {
                        "name": "PICKERING MEDICAL PRACTICE",
                        "endpoint": "TBC",
                        "receiver": {
                            "reference": "urn:uuid:3c43b5b3-06d6-445f-ae9a-48d5f05df434"
                        }
                    }
                ],
                "sender": {
                    "reference": "urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338"
                },
                "source": {
                    "endpoint": "TBC"
                },
                "focus":  [
                    {
                        "reference": "urn:uuid:35d46ca1-f253-4c97-b7ee-fb5fccdf6c20"
                    }
                ],
                "definition": "https://fhir.nhs.uk/England/MessageDefinition/England-Pathology-Report"
            }
        },
        {
            "fullUrl": "urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338",
            "resource": {
                "resourceType": "Organization",
                "id": "8a6d85b8-9837-4fed-a257-4cf207988338",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Organization"
                    ]
                },
                "identifier":  [
                    {
                        "system": "https://fhir.nhs.uk/Id/ods-organization-code",
                        "value": "Y8J7D"
                    }
                ],
                "name": "TD008362 PATH LAB 001",
                "address":  [
                    {
                        "line":  [
                            "PATHOLOGY LAB",
                            "7-8 WELLINGTON PLACE"
                        ],
                        "city": "LEEDS",
                        "district": "WEST YORKSHIRE",
                        "postalCode": "LS1 4AP"
                    }
                ]
            }
        },
        {
            "fullUrl": "urn:uuid:3c43b5b3-06d6-445f-ae9a-48d5f05df434",
            "resource": {
                "resourceType": "Organization",
                "id": "3c43b5b3-06d6-445f-ae9a-48d5f05df434",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Organization"
                    ]
                },
                "identifier":  [
                    {
                        "system": "https://fhir.nhs.uk/Id/ods-organization-code",
                        "value": "B82033"
                    }
                ],
                "name": "PICKERING MEDICAL PRACTICE",
                "address":  [
                    {
                        "line":  [
                            "SOUTHGATE"
                        ],
                        "city": "PICKERING",
                        "district": "NORTH YORKSHIRE",
                        "postalCode": "YO18 8BL"
                    }
                ]
            }
        },
        {
            "fullUrl": "urn:uuid:9a835acf-d715-4d84-8dcf-a8435f6417fe",
            "resource": {
                "resourceType": "Practitioner",
                "id": "9a835acf-d715-4d84-8dcf-a8435f6417fe",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Practitioner"
                    ]
                },
                "identifier":  [
                    {
                        "system": "https://fhir.hl7.org.uk/Id/gmc-number",
                        "value": "C1008215"
                    }
                ],
                "name":  [
                    {
                        "use": "official",
                        "family": "GASKELL",
                        "given":  [
                            "Gale"
                        ],
                        "prefix":  [
                            "Dr"
                        ]
                    }
                ]
            }
        },
        {
            "fullUrl": "urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4",
            "resource": {
                "resourceType": "Patient",
                "id": "ab87a3f8-1d37-44a9-804e-5e962598a6e4",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Patient"
                    ]
                },
                "identifier":  [
                    {
                        "extension":  [
                            {
                                "url": "https://fhir.hl7.org.uk/StructureDefinition/Extension-UKCore-NHSNumberVerificationStatus",
                                "valueCodeableConcept": {
                                    "coding":  [
                                        {
                                            "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-NHSNumberVerificationStatusEngland",
                                            "code": "01",
                                            "display": "Number present and verified"
                                        }
                                    ]
                                }
                            }
                        ],
                        "system": "https://fhir.nhs.uk/Id/nhs-number",
                        "value": "9727710859"
                    }
                ],
                "name":  [
                    {
                        "use": "official",
                        "family": "MOXEY",
                        "given":  [
                            "Judy"
                        ]
                    }
                ],
                "gender": "female",
                "birthDate": "2004-05-06",
                "address":  [
                    {
                        "line":  [
                            "1 CASTLEGATE"
                        ],
                        "city": "PICKERING",
                        "district": "NORTH YORKSHIRE",
                        "postalCode": "YO18 7AY"
                    }
                ]
            }
        },
        {
            "fullUrl": "urn:uuid:1c38d507-9ad7-4b49-ba91-7da204842cac",
            "resource": {
                "resourceType": "ServiceRequest",
                "id": "1c38d507-9ad7-4b49-ba91-7da204842cac",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-ServiceRequest-Lab"
                    ]
                },
                "identifier":  [
                    {
                        "system": "http://B82033-pickeringmedicalpractice.com/labrequest",
                        "value": "REQ-20220221-000018"
                    }
                ],
                "status": "active",
                "intent": "order",
                "code": {
                    "coding":  [
                        {
                            "system": "http://snomed.info/sct",
                            "code": "401324008",
                            "display": "Urinary microscopy, culture and sensitivities"
                        }
                    ]
                },
                "subject": {
                    "reference": "urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4",
                    "display": "MOXEY, Judy"
                },
                "authoredOn": "2022-02-21T10:29:00+00:00",
                "requester": {
                    "reference": "urn:uuid:9a835acf-d715-4d84-8dcf-a8435f6417fe",
                    "display": "GASKELL, Dr Gale"
                },
                "performer":  [
                    {
                        "reference": "urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338",
                        "display": "TD008362 PATH LAB 001"
                    }
                ]
            }
        },
        {
            "fullUrl": "urn:uuid:bde5b0a5-4fb3-4655-acf0-215b93aee006",
            "resource": {
                "resourceType": "Specimen",
                "id": "bde5b0a5-4fb3-4655-acf0-215b93aee006",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Specimen"
                    ]
                },
                "identifier":  [
                    {
                        "system": "http://B82033-pickeringmedicalpractice.com/specimen",
                        "value": "SPC-REQ-20220221-000024"
                    }
                ],
                "accessionIdentifier": {
                    "system": "http://Y8J7D-pathlab001.com/specimen",
                    "value": "SPC-LAB-20220221-004306"
                },
                "status": "available",
                "type": {
                    "coding":  [
                        {
                            "system": "http://snomed.info/sct",
                            "code": "122575003",
                            "display": "Urine specimen"
                        }
                    ]
                },
                "subject": {
                    "reference": "urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4",
                    "display": "MOXEY, Judy"
                },
                "receivedTime": "2022-02-21T14:58:00+00:00",
                "request":  [
                    {
                        "reference": "urn:uuid:1c38d507-9ad7-4b49-ba91-7da204842cac"
                    }
                ],
                "collection": {
                    "collectedDateTime": "2022-02-21T11:07:00+00:00"
                }
            }
        },
        {
            "fullUrl": "urn:uuid:35d46ca1-f253-4c97-b7ee-fb5fccdf6c20",
            "resource": {
                "resourceType": "DiagnosticReport",
                "id": "35d46ca1-f253-4c97-b7ee-fb5fccdf6c20",
                "meta": {
                    "profile":  [
                        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-DiagnosticReport-Lab"
                    ]
                },
                "identifier":  [
                    {
                        "system": "http://Y8J7D-pathlab001.com/report",
                        "value": "REP-20220225-006301"
                    }
                ],
                "basedOn":  [
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