HL7 FHIR Malaysia Core (MY Core) Implementation Guide
2.0.0 - ci-build

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-health-screening-nhsi

Generated Narrative: Bundle example-bundle-health-screening-nhsi

Bundle example-bundle-health-screening-nhsi of type transaction

Entry 1 - fullUrl = urn:uuid:00000080-0001-0001-0004-000000000001

Resource Composition:

Generated Narrative: Composition sample-composition-bundle-nhsi

Information Source: http://example.com

Profiles: Composition (MY Core), Composition Health Screening (MY Core)

Security Label: N (Details: [not stated] code N)

identifier: hs-123

status: Final

type: Medical history screening form

category: Form

​encounter: Encounter/encounter-placeholder

date: 2024-07-18 08:00:00+0800

author: Saifuldaulah Bin Mohd Hafiz Ngoo

title: Health Screening

​custodian: Organization/11-05060009

Events

-PeriodDetail
*2024-07-18 08:00:00+0800 --> (ongoing)No display for Composition.event.detail (concept: Medical history screening form)

Request:

POST Composition

Entry 2 - fullUrl = urn:uuid:00000080-0001-0001-0004-000000000002

Resource Patient:

Generated Narrative: Patient sample-patient-bundle-nhsi

Information Source: http://pekab40.moh.gov.my

Profile: Patient (MY Core)

AMIR ZULKIFLI(official) Male, DoB: 1992-10-05 ( http://fhir.hie.moh.gov.my/sid/patient-mrn#PEKA-921005806671A)

Active:trueDeceased:false
Other Id:http://fhir.hie.moh.gov.my/sid/my-kad-no/921005806671 (use: official, )
Contact Detail
  • ph: 01156404217(Mobile)
  • BANGI KAJANG 43000 MYS
Links:
ExtensionAudit (MY Core):
  • recorder: SAIFULDAULAH BIN MOHD HAFIZ NGOO
  • recordedDate: 2023-05-11 07:01:51+0000
  • lastUpdater: SAIFULDAULAH BIN MOHD HAFIZ NGOO

Request:

POST Patient
If-None-Exist = ?identifier=http://fhir.hie.moh.gov.my/sid/patient-mrn|PEKA-921005806671A

Entry 3 - fullUrl = urn:uuid:00000080-0001-0001-0004-000000000003

Resource Encounter:

Generated Narrative: Encounter sample-encounter-bundle-nhsi

Information Source: http://sample.com

Profile: Encounter (MY Core)

ExtensionPoliceCase (MY Core): false

ExtensionVisitType (My Core): New

my/StructureDefinition/internal-referral-my-core: false

ExtensionAudit (MY Core)

identifier: http://fhir.hie.moh.gov.my/sid/encounter-id/PEKA-ENC-12345

status: completed

class: Outpatient

priority: Routine

type: National Health Screening (NHSI)

serviceType: No display for Encounter.serviceType (concept: Outpatient)

​subject: Patient/ca211a37-a7b9-42f7-a853-70cbb2f8f295

​serviceProvider: Organization/11-05060009

Participants

-TypePeriod
*attender2024-07-18 10:26:44+0800 --> (ongoing)

Diagnoses

-ConditionUse
*No display for Encounter.diagnosis.condition (reference: ->Condition/ca211a37-a7b9-42f7-a853-70cbb2f8f295)Main Diagnosis

Request:

POST Encounter
If-None-Exist = ?identifier=http://fhir.hie.moh.gov.my/sid/encounter-id|PEKA-ENC-12345

Entry 4 - fullUrl = urn:uuid:00000011-0001-0001-0004-000000000001

Resource Observation:

Generated Narrative: Observation sample-observation-anthropometry-panel-bundle-nhsi

status: Final

code: Anthropometry panel

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

hasMember:

Request:

POST Observation

Entry 5 - fullUrl = urn:uuid:00000011-0005-0005-0004-000000000002

Resource Observation:

Generated Narrative: Observation sample-observation-bmi-bundle-nhsi

version: 1; Last updated: 2024-07-21 20:52:25+0800;

Information Source: http://pekab40.moh.gov.my

Profile: Observation Body Mass Index (MY Core)

status: Final

code: BMI

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

value: 19.5 kg/m2 (Details: UCUM codekg/m2 = 'kg/m2')

Request:

POST Observation

Entry 6 - fullUrl = urn:uuid:00000011-0005-0005-0004-000000000003

Resource Observation:

Generated Narrative: Observation sample-observation-height-bundle-nhsi

status: Final

code: Height

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

value: 168 cm (Details: UCUM codecm = 'cm')

Request:

POST Observation

Entry 7 - fullUrl = urn:uuid:00000011-0005-0005-0004-000000000004

Resource Observation:

Generated Narrative: Observation sample-observation-waist-bundle-nhsi

status: Final

code: Waist Circumference

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

value: 28 cm (Details: UCUM codecm = 'cm')

Request:

POST Observation

Entry 8 - fullUrl = urn:uuid:00000011-0005-0005-0004-000000000005

Resource Observation:

Generated Narrative: Observation sample-observation-weight-bundle-nhsi

status: Final

code: Weight

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

value: 55 kg (Details: UCUM codekg = 'kg')

Request:

POST Observation

Entry 9 - fullUrl = urn:uuid:00000011-0001-0001-0003-000000000001

Resource Observation:

Generated Narrative: Observation sample-observation-vital-sign-panel-bundle-nhsi

status: Final

code: Vital Sign Panel

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder/_history/1

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

hasMember:

Request:

POST Observation

Entry 10 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000002

Resource Observation:

Generated Narrative: Observation sample-observation-heart-rate-bundle-nhsi

status: Final

code: Heart Rate

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder/_history/1

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

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 11 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000003

Resource Observation:

Generated Narrative: Observation sample-observation-respi-rate-bundle-nhsi

status: Final

code: Respiratory Rate

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder/_history/1

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

value: 16 /min (Details: UCUM code/min = '/min')

Request:

POST Observation

Entry 12 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000004

Resource Observation:

Generated Narrative: Observation sample-observation-oxygen-sat-bundle-nhsi

status: Final

code: Oxygen Saturation

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder/_history/1

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

value: 94 % (Details: UCUM code% = '%')

Request:

POST Observation

Entry 13 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000005

Resource Observation:

Generated Narrative: Observation sample-observation-systolic-bp-bundle-nhsi

status: Final

code: systolic BP

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder/_history/1

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

value: 80 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

Request:

POST Observation

Entry 14 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000006

Resource Observation:

Generated Narrative: Observation sample-observation-diastolic-bp-bundle-nhsi

status: Final

code: Diastolic BP

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder/_history/1

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

value: 60 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

Request:

POST Observation

Entry 15 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000007

Resource Observation:

Generated Narrative: Observation sample-observation-body-temp-bundle-nhsi

status: Final

code: Temperature

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder/_history/1

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

value: 31 Cel (Details: UCUM codeCel = 'Cel')

Request:

POST Observation

Entry 16 - fullUrl = urn:uuid:00000011-0005-0005-0005-000000000008

Resource Observation:

Generated Narrative: Observation sample-observation-pain-score-bundle-nhsi

status: Final

code: Pain Score

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder/_history/1

effective: 2024-07-01 08:00:00+0800

issued: 2024-07-01 08:00:00+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

value: 8

Request:

POST Observation

Entry 17 - fullUrl = urn:uuid:00000111-0001-0001-0003-000000000001

Resource DiagnosticReport:

Generated Narrative: DiagnosticReport sample-diagnostic-report-bundle-nhsi

Hemoglobin A1c/Hemoglobin.total (HbA1c) (Laboratory Procedure)

SubjectUnable to get Patient Details
When For2024-07-01 12:25:35+0800
Reported2024-07-01 12:25:35+0800

Report Details

CodeValue
The observation 'Observation/02d0e4f9-b7a0-4f9d-b68c-2d6eae4b0d03' could not be resolved

7.2%

Request:

POST DiagnosticReport

Entry 18 - fullUrl = urn:uuid:00000111-0005-0005-0005-000000000002

Resource Observation:

Generated Narrative: Observation sample-observation-lab-result-bundle-nhsi

status: Final

category: Laboratory

code: Hemoglobin A1c/Hemoglobin.total (HbA1c)

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder/_history/1

effective: 2023-09-07 08:00:00+0800

issued: 2023-09-07 08:00:00+0800

performer: SAIFULDAULAH BIN MOHD HAFIZ NGOO

component

code: Hemoglobin A1c/Hemoglobin.total (HbA1c)

value: 7.2 % (Details: UCUM code% = '%')

ReferenceRanges

-High
*6.5

Request:

POST Observation

Entry 19 - fullUrl = urn:uuid:00000111-0005-0005-0005-000000000003

Resource QuestionnaireResponse:

Generated Narrative: QuestionnaireResponse sample-questionnaire-response-qaudit10-bundle-nhsi

version: 3; Last updated: 2024-07-22 11:08:09+0800;

Information Source: http://pekab40.moh.gov.my

Profile: QuestionnaireResponse (MY Core)

LinkIDTextDefinitionAnswerdoco
.. sample-questionnaire-response-qaudit10-bundle-nhsiQuestionnaire:Questionnaire[http://fhir.hie.moh.gov.my/Questionnaire/q-audit-10|2.0.0]
... 00Please select your genderAdministrativeGender male: male
... 01How often do you have a drink containing alcohol?LOINC LA18933-4: Monthly or less
... 02How many standard drinks containing alcohol do you have on a typical day when drinking?LOINC LA18926-8: 3 or 4
... 03How often do you have six or more drinks on one occasion?LOINC LA18926-8: Less than monthly
... 04During the past year, how often have you found that you were not able to stop drinking once you had started?LOINC LA18933-4: Less than monthly
... 05During the past year, how often have you failed to do what was normally expected of you because of drinking?LOINC LA18891-4: Weekly
... 06During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?LOINC LA18891-4: Weekly
... 07During the past year, how often have you had a feeling of guilt or remorse after drinking?LOINC LA18876-5: Monthly
... 08During the past year, how often have you been unable to remember what happened the night before because you had been drinking?LOINC LA18876-5: Monthly
... 09Have you or someone else been injured as a result of your drinking?LOINC LA32280-2: Yes, during the past year
... 10Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?LOINC LA32279-4: Yes, but not in the past year
... 11Total score [AUDIT]20
... 12Outcome Summary [AUDIT]CodeSystemOutcomeAudit10 (MY Core) a3: Likelihood of alcohol dependence (moderate-severe alcohol use disorder)

doco Documentation for this format

Request:

POST QuestionnaireResponse

Entry 20 - fullUrl = urn:uuid:00000111-0005-0005-0005-000000000004

Resource Observation:

Generated Narrative: Observation sample-observation-smoking-history-bundle-nhsi

version: 2; Last updated: 2024-07-22 09:10:53+0800;

Information Source: http://pekab40.moh.gov.my#oXjuIz1WcN59J4KV

Profile: Observation Smoking History (MY Core)

status: Final

category: Social History

code: Smoking History

​subject: Patient/patient-placeholder

effective: 2024-07-16 14:40:57+0800

issued: 2024-07-16 14:40:57+0800

performer: Saifuldaulah Bin Mohd Hafiz Ngoo

note: <div xmlns="http://www.w3.org/1999/xhtml"><table><tbody><tr><td>Smoking Status</td><td>true</td></tr><tr><td>Lifetime smoking use</td><td>15 years</td></tr><tr><td>Date quit smoking</td><td>19/7/2024</td></tr></tbody><tfoot><tr><td>Smoking device</td><td>Cigarette</td></tr><tr><td>Smoking history</td><td>&nbsp;Patient has been smoking for the past 15 years, have plan to quit now</td></tr></tfoot></table><p>&nbsp;</p></div>

component

code: Smoking status

value: true

component

code: Lifetime smoking use

value: 15 years (Details: UCUM codea = 'a')

component

code: Date quit smoking

value: 2024-07-19

component

code: Smoking product

value: Cigarette

component

code: Smoking History

value: <div xmlns="http://www.w3.org/1999/xhtml">Patient has been smoking for the past 15 years, have plan to quit now</div>

Request:

POST Observation

Entry 21 - fullUrl = urn:uuid:00000111-0005-0005-0005-000000000005

Resource Condition:

Generated Narrative: Condition sample-condition-encounter-diagnosis-bundle-nhsi

ExtensionAudit (MY Core)

  • lastUpdater: SAIFULDAULAH BIN MOHD HAFIZ NGOO

clinicalStatus: resolved

category: Encounter Diagnosis

code: Pneumonia

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder

onset: 2024-07-01 00:00:00+0800

abatement: 2024-07-17 00:00:00+0800

recordedDate: 2024-07-22 08:31:00+0800

Request:

POST Condition

Entry 22 - fullUrl = urn:uuid:00000111-0005-0005-0005-000000000006

Resource Condition:

Generated Narrative: Condition sample-condition-comorbidities-1-bundle-nhsi

ExtensionAudit (MY Core)

  • lastUpdater: SAIFULDAULAH BIN MOHD HAFIZ NGOO

clinicalStatus: Active

category: Comorbidities Item

code: Essential hypertension

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder

recordedDate: 2024-07-22 08:22:00+0800

Request:

POST Condition

Entry 23 - fullUrl = urn:uuid:00000111-0005-0005-0005-000000000007

Resource Condition:

Generated Narrative: Condition sample-condition-comorbidities-2-bundle-nhsi

ExtensionAudit (MY Core)

  • lastUpdater: SAIFULDAULAH BIN MOHD HAFIZ NGOO

clinicalStatus: Active

category: Comorbidities Item

code: Type 2 diabetes mellitus

​subject: Patient/patient-placeholder

​encounter: Encounter/encounter-placeholder

recordedDate: 2024-07-22 08:22:00+0800

Request:

POST Condition