Generated Narrative: Patient Patient-referral-summary-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
Generated Narrative: Encounter Encounter-referral-summary-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: Finished statusHistory status: Planned period: 2023-04-26 08:00:00+0800 --> 2023-04-26 09:00:00+0800 statusHistory status: Arrived period: 2023-04-26 08:00:00+0800 --> 2023-04-26 08:15:00+0800 statusHistory status: In Progress period: 2023-04-26 08:15:00+0800 --> 2023-04-26 09:00:00+0800 class: CodeSystemEncounterClass (MY Core) AMB: Outpatient type: General Health screening serviceType: Outpatient priority: Routine subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001 Participants - Type Individual * primary performer Saifuldaulah Bin Mohd Hafiz Ngoo (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/81751) period: 2023-01-20 08:00:00+0800 --> 2023-01-20 12:00:00+0800 diagnosis condition: Condition/urn:uuid:00000001-0001-0001-0003-000000000001 use: Admission diagnosis diagnosis condition: Condition/urn:uuid:00000001-0001-0001-0003-000000000001 use: Discharge diagnosis diagnosis condition: Condition/urn:uuid:00000001-0001-0001-0003-000000000001 use: Main Diagnosis diagnosis condition: Condition/urn:uuid:00000001-0001-0001-0003-000000000001 use: Other Diagnosis diagnosis condition: Cranioplasty use: Other Diagnosis serviceProvider: Hospital Tuanku Ja'afar, Seremban
Generated Narrative: ServiceRequest ServiceRequest-referral-summary-no-id Last updated: 2023-04-09 23:19:39+0800; Information Source: sample Profile: ServiceRequest (MY Core) Security Label: normal (Details: Confidentiality code N = 'normal') ExtensionAttester (MY Core) mode: professional time: 2022-10-05 07:14:38+0800 party: Murusamy A/L Atharv (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/43217) identifier: http://fhir.hie.moh.gov.my/sid/service-request-id/HTJ-REF-2304000005 status: Active intent: Proposal category: Patient referral priority: Routine code: Hospital Referral Summary subject: Patient/urn:uuid:00000001-0001-0001-0001-000000000001 encounter: Encounter/urn:uuid:00000001-0001-0001-0002-000000000001 authoredOn: 2022-08-30 08:00:46+0800 requester: Wong Ah Liu (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/76212) performerType: Internal performer: Organization/11-05060009 Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345) reasonReference: Condition/urn:uuid:00000001-0001-0001-0003-000000000001 supportingInfo: Zuraidah Binti Abu note: History & Physical Findings: Results of Investigations: Diagnosis: Treatment: Referral Reason:
History & Physical Findings: Results of Investigations: Diagnosis: Treatment: Referral Reason:
Generated Narrative: Condition Condition-referral-summary-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 recorder: Saw Lee Chin (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/64325)
Generated Narrative: AllergyIntolerance AllergyIntolerance-referral-summary-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 recorder: Saw Lee Chin (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/64325) asserter: Tee Wei Sian (Identifier: http://fhir.hie.moh.gov.my/sid/nsr-no/52416) lastOccurrence: 2022-06-20 09:00:00+0800 reaction ExtensionFormularyBoolean (MY Core): true substance: Kabiven Central 1900kcal, 2.053L manifestation: Acneiform, Alopecia, Erythema multiforme description: Aspirin onset: 2022-06-25 09:00:00+0800 severity: Moderate exposureRoute: Oral use note: By @2022-06-25 09:00:00+0800 Additional entry related to allergy reaction details
Additional entry related to allergy reaction details
Generated Narrative: Observation ObservationLabResult-referral-summary-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) / Immature platelet fraction (IPF) / Reticulocyte count 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% = '%')
Full Blood Count (FBC) / Immature platelet fraction (IPF) / Reticulocyte count
Generated Narrative: DiagnosticReport DiagnosticReport-referral-summary-no-id Last updated: 2023-04-11 13:43:55+0800; Information Source: sample Profile: DiagnosticReport (MY Core) Full Blood Count (FBC) / Immature platelet fraction (IPF) / Reticulocyte count (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
This is a computer generated report. No signature is required
Generated Narrative: MedicationRequest MedicationRequest-referral-summary-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 medication: Diphenhydramine HCl Expectorant (Adult) 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')
Generated Narrative: Procedure Procedure-referral-summary-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: Cranial puncture subject: Bundle: type = transaction encounter: Bundle: type = transaction performed: 2022-12-26 15:30:00+0800 --> 2022-12-26 18:00:00+0800 recorder: Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345) asserter: Wong Ah Liu (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/76212) 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: Complication 1, Complication 2 note: By @2022-12-26 18:10:00+0800 Procedure%20note
Generated Narrative: Observation obs-vs-sample-referral-summary-no-id Last updated: 2023-04-11 13:43:55+0800; Information Source: sample Profile: Observation Vital Sign 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
Generated Narrative: Observation ObservationHeartRate-referral-summary-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
Generated Narrative: Observation ObservationRespiRate-referral-summary-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
Generated Narrative: Observation ObservationOxygenSat-referral-summary-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
Generated Narrative: Observation ObservationSystolicBp-referral-summary-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
Generated Narrative: Observation ObservationDiastolicBp-referral-summary-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
Generated Narrative: Observation ObservationBodyTemp-referral-summary-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
Generated Narrative: Observation ObservationPainScore-referral-summary-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