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
{
"resourceType" : "Bundle",
"id" : "example-bundle-lab-report-no-id",
"type" : "transaction",
"entry" : [
{
"fullUrl" : "urn:uuid:00000001-0001-0001-0001-000000000001",
"resource" : {
"resourceType" : "DiagnosticReport",
"id" : "sample-diagnostic-report-no-id",
"meta" : {
"source" : "sample",
"profile" : [
🔗 "http://fhir.hie.moh.gov.my/StructureDefinition/DiagnosticReport-my-core"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"DiagnosticReport_sample-diagnostic-report-no-id\"> </a><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport sample-diagnostic-report-no-id</b></p><a name=\"sample-diagnostic-report-no-id\"> </a><a name=\"hcsample-diagnostic-report-no-id\"> </a><a name=\"sample-diagnostic-report-no-id-en-US\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Information Source: sample</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-DiagnosticReport-my-core.html\">DiagnosticReport (MY Core)</a></p></div><h2><span title=\"Codes:{http://loinc.org 58410-2}\">Full Blood Count (FBC)</span> (<span title=\"Codes:{http://fhir.hie.moh.gov.my/CodeSystem/servicerequest-category-my-core 108252007}\">Laboratory Procedure</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td>Not done yet</td></tr><tr><td>When For</td><td>2022-12-26 08:00:08+0800</td></tr><tr><td>Reported</td><td>2022-12-26 08:00:00+0800</td></tr><tr><td>Performers</td><td> 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 Ghazali (Identifier: amended_by)</td></tr><tr><td>Identifier</td><td> <code>http://fhir.hie.moh.gov.my/sid/barcode</code>/0000001000</td></tr></table><p><b>Report Details</b></p><table class=\"grid\"><tr><td><b>Code</b></td><td><b>Value</b></td></tr><tr><td/><td/></tr></table><p>This is a computer generated report. No signature is required</p></div>"
},
"extension" : [
{
"url" : "http://fhir.hie.moh.gov.my/StructureDefinition/printed-date-my-core",
"valueDateTime" : "2022-03-27T08:00:08+08:00"
},
{
"extension" : [
{
"url" : "amendedDate",
"valueDateTime" : "2022-03-27T08:00:08+08:00"
},
{
"url" : "amendedReason",
"valueCodeableConcept" : {
"text" : "Amended Reason remark goes here"
}
}
],
"url" : "http://fhir.hie.moh.gov.my/StructureDefinition/amended-reason-my-core"
}
],
"identifier" : [
{
"system" : "http://fhir.hie.moh.gov.my/sid/barcode",
"value" : "0000001000"
}
],
"status" : "amended",
"category" : [
{
"coding" : [
{
"system" : "http://fhir.hie.moh.gov.my/CodeSystem/servicerequest-category-my-core",
"code" : "108252007",
"display" : "Laboratory Procedure"
}
]
}
],
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "58410-2",
"display" : "Full Blood Count (FBC)"
}
]
},
"subject" : {
"reference" : "Patient/patient-sample"
},
"encounter" : {
"reference" : "Encounter/encounter-sample"
},
"effectiveDateTime" : "2022-12-26T08:00:08+08:00",
"issued" : "2022-12-26T08:00:00+08:00",
"performer" : [
{
"type" : "PractitionerRole",
"identifier" : {
"value" : "primary_performer"
},
"display" : "Amirul Bin Azhar"
},
{
"type" : "PractitionerRole",
"identifier" : {
"value" : "secondary_performer"
},
"display" : "Izzudin Bin Zaid"
},
{
"type" : "PractitionerRole",
"identifier" : {
"value" : "verified_by"
},
"display" : "Nizam Bin Zulkifli"
},
{
"type" : "PractitionerRole",
"identifier" : {
"value" : "validated_by"
},
"display" : "Nizar Bin Zubir"
},
{
"type" : "PractitionerRole",
"identifier" : {
"value" : "printed_by"
},
"display" : "Akasyah Bin Ibrahim"
},
{
"type" : "PractitionerRole",
"identifier" : {
"value" : "amended_by"
},
"display" : "Afiq Bin Ghazali"
}
],
"resultsInterpreter" : [
{
"type" : "PractitionerRole",
"identifier" : {
"system" : "http://fhir.hie.moh.gov.my/sid/mmc-no",
"value" : "12345"
},
"display" : "Arumugan A/L Aryan"
}
],
"result" : [
{
"reference" : "Observation/obs-lab-sample"
}
],
"conclusion" : "This is a computer generated report. No signature is required"
},
"request" : {
"method" : "POST",
"url" : "DiagnosticReport"
}
},
{
"fullUrl" : "urn:uuid:00000001-0001-0001-0002-000000000001",
"resource" : {
"resourceType" : "Observation",
"id" : "sample-lab-result-no-id",
"meta" : {
"source" : "sample",
"profile" : [
🔗 "http://fhir.hie.moh.gov.my/StructureDefinition/Observation-lab-result-my-core"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_sample-lab-result-no-id\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation sample-lab-result-no-id</b></p><a name=\"sample-lab-result-no-id\"> </a><a name=\"hcsample-lab-result-no-id\"> </a><a name=\"sample-lab-result-no-id-en-US\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Information Source: sample</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-Observation-lab-result-my-core.html\">Observation Lab Result (MY Core)</a></p></div><p><b>identifier</b>: <code>http://fhir.hie.moh.gov.my/sid/barcode</code>/00021</p><p><b>status</b>: Final</p><p><b>category</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/observation-category laboratory}\">Laboratory</span></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 58410-2}\">Full Blood Count (FBC)</span></p><p><b>subject</b>: <a href=\"Bundle-example-bundle-encounter-summary.html#Patient_patient-sample\">Bundle: type = transaction</a></p><p><b>encounter</b>: <a href=\"Bundle-example-bundle-encounter-summary.html#Encounter_encounter-sample\">Bundle: type = transaction</a></p><p><b>effective</b>: 2022-10-11 11:48:54+0800</p><p><b>issued</b>: 2022-10-11 11:53:54+0800</p><p><b>performer</b>: Arumugan A/L Aryan (Identifier: <code>http://fhir.hie.moh.gov.my/sid/mmc-no</code>/12345)</p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">White Blood Cell Count</span></p><p><b>value</b>: 16.97 10*3/uL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code10*3/uL = '10*3/uL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>4.078</td><td>11.37</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Red Blood Cell Count</span></p><p><b>value</b>: 3.85 10*6/uL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code10*6/uL = '10*6/uL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation L}\">low</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>4.53</td><td>5.95</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Hemoglobin</span></p><p><b>value</b>: 6.7 g/dL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codeg/dL = 'g/dL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation LL}\">Critical low</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>13.5</td><td>17.4</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Hematocrit</span></p><p><b>value</b>: 20.5 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation L}\">Low</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>40.1</td><td>50.6</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Mean Cell Volume</span></p><p><b>value</b>: 53.2 fL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codefL = 'fL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation L}\">Low</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>26.9</td><td>32.3</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Mean Cell Haemoglobin</span></p><p><b>value</b>: 17.4 pg<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codepg = 'pg')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation L}\">Low</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>26.9</td><td>32.3</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Mean Cell Haemoglobin Concentration</span></p><p><b>value</b>: 32.7 g/dL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codeg/dL = 'g/dL')</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>31.9</td><td>35.3</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Platelet</span></p><p><b>value</b>: 626 10*3/uL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code10*3/uL = '10*3/uL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>142</td><td>350</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Red Cell Distribution Width - SD</span></p><p><b>value</b>: fL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codefL = 'fL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>4.078</td><td>11.37</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Red Cell Distribution Width - CV</span></p><p><b>value</b>: 31.9 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>12</td><td>14.8</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Platelet Distribution Width</span></p><p><b>value</b>: fL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codefL = 'fL')</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Mean Platelet Volume</span></p><p><b>value</b>: fL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM codefL = 'fL')</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Platelet Large Cell Ratio</span></p><p><b>value</b>: %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Plateletcrit</span></p><p><b>value</b>: %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Absolute Neutrophil</span></p><p><b>value</b>: 8.75 10*3/uL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code10*3/uL = '10*3/uL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>3.929</td><td>7.147</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Absolute Lymphocyte</span></p><p><b>value</b>: 6.45 10*3/uL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code10*3/uL = '10*3/uL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>1.847</td><td>4.807</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Absolute Monocyte</span></p><p><b>value</b>: 1.07 10*3/uL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code10*3/uL = '10*3/uL')</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>0.385</td><td>1.141</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Absolute Eosinophil</span></p><p><b>value</b>: 0.5 10*3/uL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code10*3/uL = '10*3/uL')</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>0.827</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Absolute Basophil</span></p><p><b>value</b>: 0.2 10*3/uL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code10*3/uL = '10*3/uL')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>0</td><td>0.095</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Immature Granulocyte</span></p><p><b>value</b>: 0.21 10*3/uL<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code10*3/uL = '10*3/uL')</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Percentage of Neutrophil</span></p><p><b>value</b>: 51.6 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Percentage of Lymphocyte</span></p><p><b>value</b>: 38 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Percentage of Monocyte</span></p><p><b>value</b>: 6.3 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Percentage of Eosinophil</span></p><p><b>value</b>: 2.9 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p><p><b>interpretation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation H}\">High</span></p><h3>ReferenceRanges</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Low</b></td><td><b>High</b></td></tr><tr><td style=\"display: none\">*</td><td>4.078</td><td>11.37</td></tr></table></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Percentage of Basophil</span></p><p><b>value</b>: 1.2 %<span style=\"background: LightGoldenRodYellow\"> (Details: UCUM code% = '%')</span></p></blockquote></div>"
},
"identifier" : [
{
"system" : "http://fhir.hie.moh.gov.my/sid/barcode",
"value" : "00021"
}
],
"status" : "final",
"category" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/observation-category",
"code" : "laboratory",
"display" : "Laboratory"
}
]
}
],
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "58410-2",
"display" : "Full Blood Count (FBC)"
}
]
},
"subject" : {
"reference" : "Patient/patient-sample"
},
"encounter" : {
"reference" : "Encounter/encounter-sample"
},
"effectiveDateTime" : "2022-10-11T11:48:54+08:00",
"issued" : "2022-10-11T11:53:54+08:00",
"performer" : [
{
"type" : "PractitionerRole",
"identifier" : {
"system" : "http://fhir.hie.moh.gov.my/sid/mmc-no",
"value" : "12345"
},
"display" : "Arumugan A/L Aryan"
}
],
"component" : [
{
"code" : {
"coding" : [
{
"code" : "01",
"display" : "White Blood Cell Count"
}
]
},
"valueQuantity" : {
"value" : 16.97,
"unit" : "10*3/uL",
"system" : "http://unitsofmeasure.org",
"code" : "10*3/uL"
},
"interpretation" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
"code" : "H",
"display" : "High"
}
]
}
],
"referenceRange" : [
{
"low" : {
"value" : 4.078
},
"high" : {
"value" : 11.37
}
}
]
},
{
"code" : {
"coding" : [
{
"code" : "02",
"display" : "Red Blood Cell Count"
}
]
},
"valueQuantity" : {
"value" : 3.85,
"unit" : "10*6/uL",
"system" : "http://unitsofmeasure.org",
"code" : "10*6/uL"
},
"interpretation" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
"code" : "L",
"display" : "low"
}
]
}
],
"referenceRange" : [
{
"low" : {
"value" : 4.53
},
"high" : {
"value" : 5.95
}
}
]
},
{
"code" : {
"coding" : [
{
"code" : "03",
"display" : "Hemoglobin"
}
]
},
"valueQuantity" : {
"value" : 6.7,
"unit" : "g/dL",
"system" : "http://unitsofmeasure.org",
"code" : "g/dL"
},
"interpretation" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation",
"code" : "LL",
"display" : "Critical low"
}
]
}
],
"referenceRange" : [
{
"low" : {
"value" : 13.5
},
"high" : {
"value" : 17.4
}
}
]
},
{
"code" : {
"coding" : [
{
"code" : "04",
"display" : "Hematocrit"
}
]
},
"valueQuantity" : {
"value" : 20.5,
"unit" : "%",
"system" : "http://unitsofmeasure.org",
"code" : "%"
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