This example of the body of reports shows the following observation from what are usually free text reports. The text within these examples that begins with **-- and ends with --** are explanatory comments, not a formal part of the message. The following outline shows the segments that are included in this example message.
a) patient identifying record (PID)
b) EKG order record (OBR)
c) EKG coded result record (OBX)
d) EKG result records (OBX):
1) ventricular rate
2) atrial rate
3) QRS width
4) PR interval
e) order record for chest x-ray (OBR)
f) two diagnostic impressions for CXR (OBX)
g) description record for CXR (OBX)
h) a recommendation record for CXR (OBX)
i) an order record for surgical pathology (OBR)
j) a gross description record for pathology showing use of anatomy fields (OBX)
k) a microscopic description record for pathology (OBX)
l) vital signs request (OBR)
m) six vital signs (OBX)
n) part of the physical history (OBR & OBX)
o) end record
MSH|...
PID|...
**--Order record for EKG--**
OBR|1|P8753^OE|EK5230^EKG|93000^EKG|R|198703281530|198703290800|||401
0^INTERN^JOE^^^^MD^L|N <CR>
**--Two interpretation records for EKG--**
**--[In this case, the result observation ID assumes the observation code in the order
record.]--**
OBX|1|CE|&IMP|1|^Sinus bradycardia|||A|||F <CR>
OBX|2|CE|&IMP|2|^Occasional PVCs|||A|||F <CR>
**--Four numeric results for EKG--**
**--[The AS4 code is an extension of the CPT4 code (93000) for EKG plus extension .1,
.2, etc., as detailed in the Implementation Guide.]--**
OBX|3|ST|8897-1^QRS COMPLEX:NRAT:PT:CARDIAC VENTRICLES:QN:EKG^LN|
|80|/min|60-100||||F <CR>
OBX|4|ST|8894-8^P WAVE:NRAT:PT:CARDIAC ATRIA:QN:^LN||80|/min
|60-100||||F <CR>
OBX|5|ST|8633-0^QRS DURATION:TIM:PT:HEART:QN:EKG^LN||.08|msec
|.06-.10||||F <CR>
OBX|6|ST|8625-6^P-R INTERVAL:TIM:OT:HEART:QN:EKG^LN||.22|msec
|.18-.22||||F <CR>
**--Order record for CXR--**
OBR|2|P8754^OE|XR1501^XR|71020^Chest Xray AP & Lateral|R|198703281530|198703290800|||
401-0^INTERN^JOE^^^^MD^L|N <CR>
**--Two CXR diagnostic impressions--**
OBX|1|CE|71020&IMP^Radiologist's
Impression|1|.61^RUL^ACR~.212^Bronchopneumonia^ACR|||A|||F<CR>
OBX|2|CE|71020&IMP|2|51.71^Congestive heart failure^ACR|||A|||F<CR>
**--CXR Description with continuation records--**
OBX|3|TX|71020&GDT||Infiltrate probably representing bronchopneumonia in the right
lower lobe. Also pulmonary venous congestion cardiomegaly and cephalization, indicating early congestive heart failure.<CR>
**--Recommendations about CXR report to follow up one month with a repeat CXR--**
OBX|4|CE|71020&REC||71020^Followup CXR 1 month^AS4||||||F<CR>
**--Order record for pathology report--**
OBR|3|P8755^OE|SP89-739^SP|88304^Surgical Path
Report|R|198703281530|198703290800|||401-0^INTERN^JOE^^^^MD^L|N<CR>
OBX|1|CE|&ANT|1|Y0480-912001^orbital region^SNM||||||F<CR>
**--Gross description record (with overflow) for pathology--**
OBX|2|TX|&GDT^GrossSpecimenDescription|1|The specimen is received in four containers. The first is labeled with the patient's name and consists of three fragments of reddish-brown tissue each of which measures 2 mm in greatest dimension. They are wrapped in tissue paper and submitted in toto in a single cassette| <CR>
**--Microscopic description record for pathology--**
OBX|3|TX|&MDT^MicroscopicDescription|1|A|Sections of the first specimen received for frozen section diagnosis reveal thick walled, ramifying vessels lined by a single layer of flattened endothelial cells. The thick smooth muscle walls exhibit no malignant cytologic features nor do the endothelial lining cells. Within the same specimen are also found fragments of fibrous connective tissue, bone, and nerve which are histologically unremarkable||||||F<CR>
**--Vital signs--**
OBR|4|P8756^OE|N2345^NR|3000.02^VITAL SIGNS|R|198703281530|198703290800|||401-0^INTERN^JOE^^^^MD^L|N<CR>
OBX|1|ST|8462-4^INTRAVASCULAR DIASTOLIC:PRES:^LN||90|mm(hg)|60-90||||F<CR>
OBX|2|ST|8479-8^INTRAVASCULAR SYSTOLIC:PRES:^LN||120|mm(hg)
|100-160||||F<CR>
OBX|3|ST|8478-0^INTRAVASCULAR MEAN:PRES:^LN||100|mm(hg)|80-120|N|||F<CR>
OBX|4|ST|8867-4^HEART BEAT:NRAT:^LN||74|/min|60-100|N|||F<CR>
OBX|5|ST|8357-6^BLOOD PRESSURE METHOD:^LN||MANUAL BY CUFF||||||F<CR>
OBX|6|ST|8886-4^HEART RATE METHOD:^LN||MANUAL BY PALP||||||F<CR>
**--Part of the patient's history--**
OBR|5|P8568^OE|HX2230^CLN||2000^HISTORY|R|198703281530|198703290800|401
0^INTERN^JOE^^^^MD^L|N<CR>
OBX|1|CE|8661-1^CHIEF COMPLAINT:^LN|| ... <CR>
OBX|2|ST|8674-4^HISTORY SOURCE:^LN||PATIENT||||||F<CR>
OBX|3|TX|8684-3^PRESENT ILLNESS:^LN||SUDDEN ONSET OF CHEST PAIN. 2 DAYS,
PTA ASSOCIATED WITH NAUSEA, VOMITING & SOB. NO RELIEF WITH ANTACIDS
OR NTG. NO OTHER SX. NOT PREVIOUSLY ILL.||||||F<CR>
.
.
and so on.