example-bundle-complete-discharge-summary-no-id - HL7 FHIR Malaysia Core (MY Core) Implementation Guide v2.0.0

HL7 FHIR Malaysia Core (MY Core) Implementation Guide - Local Development build (v2.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example Bundle: example-bundle-complete-discharge-summary-no-id

Generated Narrative: Bundle example-bundle-complete-discharge-summary-no-id

Bundle example-bundle-complete-discharge-summary-no-id of type transaction

Entry 1 - fullUrl = urn:uuid:00000001-0001-0001-0001-000000000001

Resource Patient:

Generated Narrative: Patient patient-sample-no-id

Last updated: 2023-04-10 07:46:20+0800;
Information Source: sample
Profile: Patient (MY Core)
NURUL BINTI SALLEH Female, DoB: 1991-05-03 ( http://fhir.hie.moh.gov.my/sid/my-kad-no#910503145678)
Active: true Deceased: false
Marital Status: Never Married
Other Id: http://fhir.hie.moh.gov.my/sid/patient-mrn/HIE-00000003
Contact Detail
ph: 0102313431(Mobile)
nurulsalleh@gmail.com
ALAM SARI KAJANG 43000 MYS
Father:
SALLEH BIN ABU
ALAM SARI KAJANG 43000 MYS
ph: 01156404200(Mobile)
duniakusegitiga@gmail.com
Links:
Managing Organization: HOSPITAL TUANKU JA'AFAR
ExtensionEthnic (MY Core) Melayu
ExtensionEducationLevel (MY Core) Tertiary
ExtensionMonthlyHouseholdIncome (MY Core) < RM 500
ExtensionAudit (MY Core):
recorder: AMIN
recordedDate: 2022-10-05 07:14:38+0800
lastUpdater: ASYIQ
ExtensionReligion (MY Core) Islam
ExtensionNationality (MY Core) Malaysia
ExtensionOccupationSector (MY Core) JURU SENI

Request:

POST Patient

Entry 2 - fullUrl = urn:uuid:00000001-0001-0001-0002-000000000001

Resource Encounter:

Generated Narrative: Encounter encounter-sample-no-id

Last updated: 2023-04-08 23:51:31+0800;
Information Source: sample
Profile: Encounter (MY Core)
identifier: http://fhir.hie.moh.gov.my/sid/encounter-id/HTJ-ENC-2211000036
status: completed
class: Outpatient
priority: Routine
type: General Health screening
serviceType: No display for Encounter.serviceType (concept: Outpatient)
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
serviceProvider: Hospital Tuanku Ja'afar, Seremban
Participants
- Type
* primary performer
diagnosis
condition: No display for Encounter.diagnosis.condition (reference: ->Condition/urn:uuid:0000001-0001-0001-0004-000000000001)
use: Admission diagnosis
diagnosis
condition: No display for Encounter.diagnosis.condition (reference: ->Condition/urn:uuid:0000001-0001-0001-0004-000000000001)
use: Discharge diagnosis
diagnosis
condition: No display for Encounter.diagnosis.condition (reference: ->Condition/urn:uuid:0000001-0001-0001-0004-000000000001)
use: Main Diagnosis
diagnosis
condition: No display for Encounter.diagnosis.condition (reference: ->Condition/urn:uuid:0000001-0001-0001-0004-000000000001)
use: Other Diagnosis

Request:

POST Encounter

Entry 3 - fullUrl = urn:uuid:0000001-0001-0001-0003-000000000001

Resource Composition:

Generated Narrative: Composition composition-sample-no-id

Last updated: 2023-04-06 22:58:30+0800;
Information Source: sample
Profile: Composition (MY Core)
Security Label: normal (Details: Confidentiality code N = 'normal')
ExtensionLocationRecorded (MY Core): Ward A
identifier: http://fhir.hie.moh.gov.my/sid/composition-id/HTJ-CMP-2304000003
status: Final
type: Discharge Summary Note
category: Discharge Summary Note
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
date: 2023-04-07 06:58:00+0800
author: Saw Lee Chin (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/64325)
title: Note
Attesters
- Mode Time Party
* Professional 2023-04-07 06:58:00+0800 Kamal Bin Arifin (Identifier: http://fhir.hie.moh.gov.my/sid/nsr-no/23312)
custodian: HOSPITAL TUANKU JA'AFAR, SEREMBAN
Events
- Period Detail
* 2023-04-07 06:57:00+0800 --> (ongoing) No display for Composition.event.detail (concept: Discharge Summary Note)

Request:

POST Composition

Entry 4 - fullUrl = urn:uuid:0000001-0001-0001-0004-000000000001

Resource Condition:

Generated Narrative: Condition condition-sample-no-id

Last updated: 2023-04-10 15:47:44+0800;
Information Source: sample
Profile: Condition (MY Core)
clinicalStatus: active
category: Encounter Diagnosis
code: Dengue NOS
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
recordedDate: 2023-04-10 15:47:00+0800

Request:

POST Condition

Entry 5 - fullUrl = urn:uuid:0000001-0001-0001-0005-000000000001

Resource AllergyIntolerance:

Generated Narrative: AllergyIntolerance allergy-sample-no-id

Last updated: 2022-08-17 10:24:11+0800;
Information Source: sample
Profile: AllergyIntolerance (MY Core)
ExtensionFormularyBoolean (MY Core): true
clinicalStatus: Active
verificationStatus: Confirmed
category: Medication
code: Adenine
patient: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
recordedDate: 2022-06-25 11:00:00+0800
lastOccurrence: 2022-06-20 09:00:00+0800
reaction
ExtensionFormularyBoolean (MY Core): true
substance: Kabiven Central 1900kcal, 2.053L
manifestation: No display for AllergyIntolerance.reaction.manifestation (concept: Acneiform), No display for AllergyIntolerance.reaction.manifestation (concept: Alopecia), No display for AllergyIntolerance.reaction.manifestation (concept: Erythema multiforme)
description: Aspirin
onset: 2022-06-25 09:00:00+0800
severity: Moderate
exposureRoute: Oral use
note: Additional entry related to allergy reaction details (By null @2022-06-25 09:00:00+0800)

Request:

POST AllergyIntolerance

Entry 6 - fullUrl = urn:uuid:0000001-0001-0001-0006-000000000001

Resource Observation:

Generated Narrative: Observation obs-lab-sample-no-id

Last updated: 2023-04-11 13:43:55+0800;
Information Source: sample
Profile: Observation Lab Result (MY Core)
identifier: http://fhir.hie.moh.gov.my/sid/barcode/0000000021
status: Final
category: Laboratory
code: Full Blood Count (FBC)
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
effective: 2022-10-11 11:48:54+0800
issued: 2022-10-11 11:53:54+0800
performer: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
component
code: White Blood Cell Count
value: 16.97 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')
interpretation: High
ReferenceRanges
- Low High
* 4.078 11.37
component
code: Red Blood Cell Count
value: 3.85 10*6/uL (Details: UCUM code10*6/uL = '10*6/uL')
interpretation: low
ReferenceRanges
- Low High
* 4.53 5.95
component
code: Hemoglobin
value: 6.7 g/dL (Details: UCUM codeg/dL = 'g/dL')
interpretation: Critical low
ReferenceRanges
- Low High
* 13.5 17.4
component
code: Hematocrit
value: 20.5 % (Details: UCUM code% = '%')
interpretation: Low
ReferenceRanges
- Low High
* 40.1 50.6
component
code: Mean Cell Volume
value: 53.2 fL (Details: UCUM codefL = 'fL')
interpretation: Low
ReferenceRanges
- Low High
* 26.9 32.3
component
code: Mean Cell Haemoglobin
value: 17.4 pg (Details: UCUM codepg = 'pg')
interpretation: Low
ReferenceRanges
- Low High
* 26.9 32.3
component
code: Mean Cell Haemoglobin Concentration
value: 32.7 g/dL (Details: UCUM codeg/dL = 'g/dL')
ReferenceRanges
- Low High
* 31.9 35.3
component
code: Platelet
value: 626 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')
interpretation: High
ReferenceRanges
- Low High
* 142 350
component
code: Red Cell Distribution Width - SD
value: fL (Details: UCUM codefL = 'fL')
interpretation: High
ReferenceRanges
- Low High
* 4.078 11.37
component
code: Red Cell Distribution Width - CV
value: 31.9 % (Details: UCUM code% = '%')
interpretation: High
ReferenceRanges
- Low High
* 12 14.8
component
code: Platelet Distribution Width
value: fL (Details: UCUM codefL = 'fL')
component
code: Mean Platelet Volume
value: fL (Details: UCUM codefL = 'fL')
component
code: Platelet Large Cell Ratio
value: % (Details: UCUM code% = '%')
component
code: Plateletcrit
value: % (Details: UCUM code% = '%')
component
code: Absolute Neutrophil
value: 8.75 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')
interpretation: High
ReferenceRanges
- Low High
* 3.929 7.147
component
code: Absolute Lymphocyte
value: 6.45 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')
interpretation: High
ReferenceRanges
- Low High
* 1.847 4.807
component
code: Absolute Monocyte
value: 1.07 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')
ReferenceRanges
- Low High
* 0.385 1.141
component
code: Absolute Eosinophil
value: 0.5 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')
ReferenceRanges
- Low High
* 0 0.827
component
code: Absolute Basophil
value: 0.2 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')
interpretation: High
ReferenceRanges
- Low High
* 0 0.095
component
code: Immature Granulocyte
value: 0.21 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')
component
code: Percentage of Neutrophil
value: 51.6 % (Details: UCUM code% = '%')
component
code: Percentage of Lymphocyte
value: 38 % (Details: UCUM code% = '%')
component
code: Percentage of Monocyte
value: 6.3 % (Details: UCUM code% = '%')
component
code: Percentage of Eosinophil
value: 2.9 % (Details: UCUM code% = '%')
interpretation: High
ReferenceRanges
- Low High
* 4.078 11.37
component
code: Percentage of Basophil
value: 1.2 % (Details: UCUM code% = '%')

Request:

POST Observation

Entry 7 - fullUrl = urn:uuid:0000001-0001-0001-0007-000000000001

Resource DiagnosticReport:

Generated Narrative: DiagnosticReport dr-sample-no-id

Last updated: 2023-04-11 13:43:55+0800;
Information Source: sample
Profile: DiagnosticReport (MY Core)
Full Blood Count (FBC) (Laboratory Procedure)
Subject Unable to get Patient Details
When For 2022-12-26 08:00:08+0800
Reported 2022-12-26 08:00:00+0800
Performers Amirul Bin Azhar (Identifier: primary_performer) Izzudin Bin Zaid (Identifier: secondary_performer) Nizam Bin Zulkifli (Identifier: verified_by) Nizar Bin Zubir (Identifier: validated_by) Akasyah Bin Ibrahim (Identifier: printed_by) Afiq Bin Fhazali (Identifier: amended_by)
Identifier http://fhir.hie.moh.gov.my/sid/barcode/0000001000
Report Details
Code Value
The observation 'Observation/urn:uuid:0000001-0001-0001-0006-000000000001' could not be resolved
This is a computer generated report. No signature is required

Request:

POST DiagnosticReport

Entry 8 - fullUrl = urn:uuid:0000001-0001-0001-0008-000000000001

Resource MedicationRequest:

Generated Narrative: MedicationRequest mr-sample-no-id

Last updated: 2023-03-06 04:30:43+0800;
Information Source: sample
Profile: MedicationRequest (MY Core)
ExtensionDrugForm (MY Core): Liquid/Solution
status: Active
intent: Order
category: Inpatient
priority: Routine
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
authoredOn: 2008-06-17 10:00:00+0800
requester: Organization/21-05060049
performer: Organization/21-05060049
recorder: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
dosageInstruction
timing: Code , Duration 5?? , Once
route: Oral
DoseAndRates
- Dose[x]
* 15 ml (Details: UCUM codeml = 'ml')

Request:

POST MedicationRequest

Entry 9 - fullUrl = urn:uuid:0000001-0001-0001-0010-000000000001

Resource Procedure:

Generated Narrative: Procedure procedure--sample-no-id

Last updated: 2023-04-18 13:06:51+0800;
Information Source: http://provider.hie.moh.gov.my
Profile: Procedure (MY Core)
status: Completed
category: Surgical procedure
code: Other cranial puncture
subject: Bundle: type = transaction
encounter: Bundle: type = transaction
recorder: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
performer
function: Medical Officer
actor: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
onBehalfOf: Organization/11-05040012
performer
function: House Officer
actor: Wong Ah Liu (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/76212)
onBehalfOf: Organization/11-05060009
location: Bilik 1
bodySite: Bilateral, Deep
outcome: Successful
complication: No display for Procedure.complication (concept: ), No display for Procedure.complication (concept: )
note: <div xmlns="http://www.w3.org/1999/xhtml">Procedure%20note</div> (By null @2022-12-26 18:10:00+0800)

Request:

POST Procedure

Entry 10 - fullUrl = urn:uuid:0000001-0001-0001-0009-000000000001

Resource Observation:

Generated Narrative: Observation obs-vs-panel-sample-no-id

Last updated: 2023-04-11 13:43:55+0800;
Information Source: sample
Profile: Observation Panel (MY Core)
status: Final
category: Vital Signs
code: Vital Sign Panel
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
effective: 2022-01-29 08:00:00+0800
issued: 2022-01-29 08:00:00+0800
performer: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
hasMember:
Observation/urn:uuid:00000011-0005-0005-0005-000000000002
Observation/urn:uuid:00000011-0005-0005-0005-000000000003
Observation/urn:uuid:00000011-0005-0005-0005-000000000004
Observation/urn:uuid:00000011-0005-0005-0005-000000000005
Observation/urn:uuid:00000011-0005-0005-0005-000000000006
Observation/urn:uuid:00000011-0005-0005-0005-000000000007
Observation/urn:uuid:00000011-0005-0005-0005-000000000008

Request:

POST Observation

Entry 11 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000002

Resource Observation:

Generated Narrative: Observation obs-heart-rate-sample-no-id

Information Source: sample
Profile: Observation Heart Rate (MY Core)
status: Final
category: Vital Signs
code: Heart Rate
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
effective: 2022-01-29 08:00:00+0800
issued: 2022-01-29 08:00:00+0800
performer: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
value: 60 /min (Details: UCUM code/min = '/min')
component
code: Heart rate device
value: mobile machine
component
code: Body position
value: sitting

Request:

POST Observation

Entry 12 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000003

Resource Observation:

Generated Narrative: Observation obs-respi-rate-sample-no-id

Information Source: sample
Profile: Observation Respiratory Rate (MY Core)
status: Final
category: Vital Signs
code: Respiratory Rate
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
effective: 2022-01-29 08:00:00+0800
issued: 2022-01-29 08:00:00+0800
performer: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
value: 16 /min (Details: UCUM code/min = '/min')
Components
- Code Value[x]
* Inhaled oxygen flow rate under NP 3L/min

Request:

POST Observation

Entry 13 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000004

Resource Observation:

Generated Narrative: Observation obs-oxygen-sat-sample-no-id

Information Source: sample
Profile: Observation Oxygen Saturation (MY Core)
status: Final
category: Vital Signs
code: Oxygen Saturation
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
effective: 2022-01-29 08:00:00+0800
issued: 2022-01-29 08:00:00+0800
performer: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
value: 94 % (Details: UCUM code% = '%')
Components
- Code Value[x]
* Inhaled oxygen flow rate under NP 3L/min

Request:

POST Observation

Entry 14 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000005

Resource Observation:

Generated Narrative: Observation obs-systolic-bp-sample-no-id

Information Source: sample
Profile: ObservationSystolicBp (MY Core)
status: Final
category: Vital Signs
code: systolic BP
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
effective: 2022-01-29 08:00:00+0800
issued: 2022-01-29 08:00:00+0800
performer: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
value: 80 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')
component
code: Blood pressure method
value: standing
component
code: Measurement site
value: Left arm
component
code: Device cuff size
value: medium
component
code: Type of device
value: mobile machine

Request:

POST Observation

Entry 15 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000006

Resource Observation:

Generated Narrative: Observation obs-diastolic-bp-sample-no-id

Information Source: sample
Profile: Observation Diastolic BP (My Core)
status: Final
category: Vital Signs
code: Diastolic BP
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
effective: 2022-01-29 08:00:00+0800
issued: 2022-01-29 08:00:00+0800
performer: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
value: 60 mm[Hg] (Details: UCUM codemm[Hg] = 'mm[Hg]')
component
code: Blood pressure method
value: standing
component
code: Measurement site
value: Left arm
component
code: Device cuff size
value: medium
component
code: Type of device
value: mobile machine

Request:

POST Observation

Entry 16 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000007

Resource Observation:

Generated Narrative: Observation obs-body-temp-sample-no-id

Information Source: sample
Profile: Observation Body Temperature (MY Core)
status: Final
category: Vital Signs
code: Temperature
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
effective: 2022-01-29 08:00:00+0800
issued: 2022-01-29 08:00:00+0800
performer: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
value: 31 Cel (Details: UCUM codeCel = 'Cel')
component
code: Body measurement site
value: Below tounge
component
code: Device
value: Thermometer
component
code: Clothing worn
value: cotton

Request:

POST Observation

Entry 17 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000008

Resource Observation:

Generated Narrative: Observation obs-pain-score-sample-no-id

Information Source: sample
Profile: Observation Pain Score (MY Core)
status: Final
category: Vital Signs
code: Pain Score
subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001
encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001
effective: 2022-01-29 08:00:00+0800
issued: 2022-01-29 08:00:00+0800
performer: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)
value: 8

Request:

POST Observation