PATH-R4-30: UKCore-Observation-Lab (Test Result) Snippets

An example of how each key UKCore-Observation-Lab data element may be populated is provided below. Please note that the examples are provided to illustrate individual data element usage; the full set of data elements may not necessarily be consistent with one another or illustrate a single, complete clinical scenario.

Refer to the UKCore-Observation-Lab profile definition for a detailed description of the supported data elements.

<Observation xmlns="http://hl7.org/fhir">
    <id value="Pathology-Observation-Lab-Sn-Example" />
    <!--  The canonical URL for the UKCore-Observation-Lab profile.  -->
    <meta>
        <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Observation-Lab" />
    </meta>
    <!--  A business identifier supplied by the laboratory that performed the test.  -->
    <identifier>
        <system value="https://tools.ietf.org/html/rfc4122" />
        <value value="2af46949-4938-4c57-bad4-c4363e1965d5" />
    </identifier>
    <!--  The status of the test result.  -->
    <status value="final" />
    <!--  The general type of test result.  -->
    <category>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/observation-category" />
            <code value="laboratory" />
            <display value="Laboratory" />
        </coding>
    </category>
    <!--  The clinical code and name of the test that was performed.  -->
    <code>
        <coding>
            <!--  SNOMED CT Observable Entity  -->
            <system value="http://snomed.info/sct" />
            <code value="1110441000000100" />
            <display value="White blood cell count in blood" />
        </coding>
    </code>
    <!--  Reference to the subject that the test relates to.  -->
    <subject>
        <reference value="urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4" />
        <display value="MOXEY, Judy" />
    </subject>
    <!--  The date and time that the test was performed.  -->
    <effectiveDateTime value="2022-02-09T08:03:00+00:00" />
    <!--  The date and time that the test result was issued.  -->
    <issued value="2022-02-09T11:17:00+00:00" />
    <!--  Reference(s) to the entity/entities that performed the test.  -->
    <performer>
        <reference value="urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338" />
        <display value="TD008362 PATH LAB 001" />
    </performer>
    <!--  The reason why a test result value has been omitted.  -->
    <dataAbsentReason>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="125154007" />
            <display value="Specimen unsatisfactory for evaluation" />
        </coding>
    </dataAbsentReason>
    <!--  A coded, categorical assessment of a test result value.  -->
    <interpretation>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation" />
            <code value="H" />
            <display value="High" />
        </coding>
    </interpretation>
    <!--  Comments relating to the test result.  -->
    <note>
        <text value="Further tests advised." />
    </note>
    <!--  The body part that was tested/observed.  -->
    <bodySite>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="49852007" />
            <display value="Structure of median cubital vein" />
        </coding>
    </bodySite>
    <!--  The method of testing/observation that was used.  -->
    <method>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="702659008" />
            <display value="Automated count" />
        </coding>
    </method>
    <!--  Reference to the specimen that was used for testing.  -->
    <specimen>
        <reference value="urn:uuid:bab0eaec-1ec5-4598-b660-90bb38a1030d" />
    </specimen>
    <!--  Guidance on how to interpret the test result value by comparison to a normal or recommended range.  -->
    <referenceRange>
        <low>
            <value value="4.00" />
            <unit value="10*9/L" />
            <system value="http://unitsofmeasure.org" />
            <code value="10^9/L" />
        </low>
        <high>
            <value value="11.00" />
            <unit value="10*9/L" />
            <system value="http://unitsofmeasure.org" />
            <code value="10^9/L" />
        </high>
    </referenceRange>
</Observation>
{
    "resourceType": "Observation",
    "id": "Pathology-Observation-Lab-Sn-Example",
    "meta": {
        "profile":  [
            "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Observation-Lab"
        ]
    },
    "identifier":  [
        {
            "system": "https://tools.ietf.org/html/rfc4122",
            "value": "2af46949-4938-4c57-bad4-c4363e1965d5"
        }
    ],
    "status": "final",
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://terminology.hl7.org/CodeSystem/observation-category",
                    "code": "laboratory",
                    "display": "Laboratory"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "1110441000000100",
                "display": "White blood cell count in blood"
            }
        ]
    },
    "subject": {
        "reference": "urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4",
        "display": "MOXEY, Judy"
    },
    "effectiveDateTime": "2022-02-09T08:03:00+00:00",
    "issued": "2022-02-09T11:17:00+00:00",
    "performer":  [
        {
            "reference": "urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338",
            "display": "TD008362 PATH LAB 001"
        }
    ],
    "dataAbsentReason": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "125154007",
                "display": "Specimen unsatisfactory for evaluation"
            }
        ]
    },
    "interpretation":  [
        {
            "coding":  [
                {
                    "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
                    "code": "H",
                    "display": "High"
                }
            ]
        }
    ],
    "note":  [
        {
            "text": "Further tests advised."
        }
    ],
    "bodySite": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "49852007",
                "display": "Structure of median cubital vein"
            }
        ]
    },
    "method": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "702659008",
                "display": "Automated count"
            }
        ]
    },
    "specimen": {
        "reference": "urn:uuid:bab0eaec-1ec5-4598-b660-90bb38a1030d"
    },
    "referenceRange":  [
        {
            "low": {
                "value": 4.00,
                "unit": "10*9/L",
                "system": "http://unitsofmeasure.org",
                "code": "10^9/L"
            },
            "high": {
                "value": 11.00,
                "unit": "10*9/L",
                "system": "http://unitsofmeasure.org",
                "code": "10^9/L"
            }
        }
    ]
}
Observation
Observation.id[0]Pathology-Observation-Lab-Sn-Example
Observation.meta[0].profile[0]https://fhir.hl7.org.uk/StructureDefinition/UKCore-Observation-Lab
Observation.identifier[0].system[0]https://tools.ietf.org/html/rfc4122
Observation.identifier[0].value[0]2af46949-4938-4c57-bad4-c4363e1965d5
Observation.status[0]final
Observation.category[0].coding[0].system[0]http://terminology.hl7.org/CodeSystem/observation-category
Observation.category[0].coding[0].code[0]laboratory
Observation.category[0].coding[0].display[0]Laboratory
Observation.code[0].coding[0].system[0]http://snomed.info/sct
Observation.code[0].coding[0].code[0]1110441000000100
Observation.code[0].coding[0].display[0]White blood cell count in blood
Observation.subject[0].reference[0]urn:uuid:ab87a3f8-1d37-44a9-804e-5e962598a6e4
Observation.subject[0].display[0]MOXEY, Judy
Observation.effective[0]2022-02-09T08:03:00+00:00
Observation.issued[0]2022-02-09T11:17:00+00:00
Observation.performer[0].reference[0]urn:uuid:8a6d85b8-9837-4fed-a257-4cf207988338
Observation.performer[0].display[0]TD008362 PATH LAB 001
Observation.dataAbsentReason[0].coding[0].system[0]http://snomed.info/sct
Observation.dataAbsentReason[0].coding[0].code[0]125154007
Observation.dataAbsentReason[0].coding[0].display[0]Specimen unsatisfactory for evaluation
Observation.interpretation[0].coding[0].system[0]http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation
Observation.interpretation[0].coding[0].code[0]H
Observation.interpretation[0].coding[0].display[0]High
Observation.note[0].text[0]Further tests advised.
Observation.bodySite[0].coding[0].system[0]http://snomed.info/sct
Observation.bodySite[0].coding[0].code[0]49852007
Observation.bodySite[0].coding[0].display[0]Structure of median cubital vein
Observation.method[0].coding[0].system[0]http://snomed.info/sct
Observation.method[0].coding[0].code[0]702659008
Observation.method[0].coding[0].display[0]Automated count
Observation.specimen[0].reference[0]urn:uuid:bab0eaec-1ec5-4598-b660-90bb38a1030d
Observation.referenceRange[0].low[0].value[0]4.00
Observation.referenceRange[0].low[0].unit[0]10*9/L
Observation.referenceRange[0].low[0].system[0]http://unitsofmeasure.org
Observation.referenceRange[0].low[0].code[0]10^9/L
Observation.referenceRange[0].high[0].value[0]11.00
Observation.referenceRange[0].high[0].unit[0]10*9/L
Observation.referenceRange[0].high[0].system[0]http://unitsofmeasure.org
Observation.referenceRange[0].high[0].code[0]10^9/L