HL7 FHIR Malaysia Core (MY Core) Implementation Guide
1.1.0 - ci-build
HL7 FHIR Malaysia Core (MY Core) Implementation Guide - Local Development build (v1.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
{
"resourceType" : "Composition",
"id" : "example-composition-health-screening-nhsi",
"meta" : {
"source" : "http://example.com",
"profile" : [
🔗 "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"🔗 ,
"http://fhir.hie.moh.gov.my/StructureDefinition/Composition-health-screening-my-core"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Composition example-composition-health-screening-nhsi</b></p><a name=\"example-composition-health-screening-nhsi\"> </a><a name=\"hcexample-composition-health-screening-nhsi\"> </a><a name=\"example-composition-health-screening-nhsi-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: <a href=\"http://example.com\">http://example.com</a></p><p style=\"margin-bottom: 0px\">Profiles: <a href=\"StructureDefinition-Composition-my-core.html\">Composition (MY Core)</a>, <a href=\"StructureDefinition-Composition-health-screening-my-core.html\">Composition Health Screening (MY Core)</a></p></div><p><b>identifier</b>: hs-123</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://loinc.org 64285-0}\">Medical history screening form</span></p><p><b>category</b>: <span title=\"Codes:{http://loinc.org LP199484-9}\">Form</span></p><p><b>encounter</b>: <a href=\"Encounter/1ed9f4c0-69a9-4cf3-abd7-27d27943ee3d\">Encounter/1ed9f4c0-69a9-4cf3-abd7-27d27943ee3d</a></p><p><b>date</b>: 2024-07-18 08:00:00+0800</p><p><b>author</b>: Saifuldaulah Bin Mohd Hafiz Ngoo</p><p><b>title</b>: Example Composition NHSI health screening</p><p><b>confidentiality</b>: normal</p><p><b>custodian</b>: <a href=\"Organization/11-05060009\">Organization/11-05060009</a></p><h3>Events</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Code</b></td><td><b>Period</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://loinc.org 64285-0}\">Medical history screening form</span></td><td>2024-07-18 08:00:00+0800 --> (ongoing)</td></tr></table></div>"
},
"identifier" : {
"value" : "hs-123"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "64285-0",
"display" : "Medical history screening form"
}
]
},
"category" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "LP199484-9",
"display" : "Form"
}
]
}
],
"subject" : {
"reference" : "Patient/patient-placeholder"
},
"encounter" : {
"reference" : "Encounter/1ed9f4c0-69a9-4cf3-abd7-27d27943ee3d"
},
"date" : "2024-07-18T08:00:00+08:00",
"author" : [
{
"type" : "PractitionerRole",
"display" : "Saifuldaulah Bin Mohd Hafiz Ngoo"
}
],
"title" : "Example Composition NHSI health screening",
"confidentiality" : "N",
"custodian" : {
"reference" : "Organization/11-05060009"
},
"event" : [
{
"code" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "64285-0",
"display" : "Medical history screening form"
}
]
}
],
"period" : {
"start" : "2024-07-18T08:00:00+08:00"
}
}
],
"section" : [
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11450-4",
"display" : "Problem list"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Status</th><th>Name</th><th>Category</th><th>Onset</th><th>Abatement</th></tr><tr><td>active</td><td>Pneumonia</td><td>Encounter Diagnosis</td><td>2024-07-01</td><td>2024-07-17</td></tr><tr><td>active</td><td><div><div>Essential hypertension</div></div></td><td>Comorbidities</td><td>N/A</td><td>N/A</td></tr><tr><td>active</td><td><div><div>Type 2 diabetes mellitus</div></div></td><td>Comorbidities</td><td>N/A</td><td>N/A</td></tr></tbody></table></div>"
},
"entry" : [
{
"reference" : "Condition/ca211a37-a7b9-42f7-a853-70cbb2f8f295"
},
{
"reference" : "Condition/3051480c-2a46-4818-b4dc-57de6159e3d8"
},
{
"reference" : "Condition/bb5460e7-cf4e-4799-8724-07f531dfa984"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8716-3",
"display" : "Vital Signs"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Parameter</th><th>Value</th><th>Unit</th></tr><tr><td>Respiratory Rate</td><td>16</td><td>/bpm</td></tr><tr><td>Oxygen Saturation</td><td>94</td><td>%</td></tr><tr><td>Heart Rate</td><td>60</td><td>/bpm</td></tr><tr><td>Systolic Blood Pressure</td><td>80</td><td>mmHg</td></tr><tr><td>Diastolic Blood Pressure</td><td>60</td><td>mmHg</td></tr><tr><td>Temperature</td><td><div><div>31</div></div></td><td>'C</td></tr><tr><td>Pain Score</td><td>8</td></tr></tbody></table></div>"
},
"entry" : [
{
"reference" : "Observation/urn:uuid:00000011-0001-0001-0003-000000000001"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "55418-8",
"display" : "Anthropometry"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Parameter</th><th>Value</th><th>Unit</th></tr><tr><td>Height</td><td>168</td><td>cm</td></tr><tr><td>Weight</td><td>55</td><td>kg</td></tr><tr><td>BMI</td><td>19.5</td><td><div><div>kg/m2</div></div></td></tr><tr><td>Waist Circumference</td><td>28</td><td>cm</td></tr></tbody></table></div>"
},
"entry" : [
{
"reference" : "Observation/urn:uuid:00000011-0001-0001-0004-000000000001"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "72166-2",
"display" : "Smoking History"
}
]
},
"text" : {
"status" : "generated",
"div" : "<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>Patient has been smoking for the past 15 years, have plan to quit now</td></tr></tfoot></table></div>"
},
"entry" : [
{
"reference" : "Observation/f1ac639e-052f-4d2f-a7dc-ebb6eb0334f2"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "74013-4",
"display" : "Alcohol Use History"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Authored Date</b>: 19-Jul-2024</p><p><b>Author</b>: SAIFULDAULAH BIN MOHD HAFIZ NGOO</p><blockquote><b>Please select your gender</b>: male<br/><br/><b>How often do you have a drink containing alcohol?</b>: Monthly or less<br/><br/><b>How many standard drinks containing alcohol do you have on a typical day when drinking?</b>: 3 or 4<br/><br/><b>How often do you have six or more drinks on one occasion?</b>: Less than monthly<br/><br/><b>During the past year, how often have you found that you were not able to stop drinking once you had started?</b>: Less than monthly<br/><br/><b>During the past year, how often have you failed to do what was normally expected of you because of drinking?</b>: Weekly<br/><br/><b>During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?</b>: Weekly<br/><br/><b>During the past year, how often have you had a feeling of guilt or remorse after drinking?</b>: Monthly<br/><br/><b>During the past year, how often have you been unable to remember what happened the night before because you had been drinking?</b>: Monthly<br/><br/><b>Have you or someone else been injured as a result of your drinking?</b>: Yes, during the past year<br/><br/><b>Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?</b>: Yes, but not in the past year<br/><br/><b>Total score [AUDIT]</b>: 20<br/><b>Outcome Summary [AUDIT]</b>: Likelihood of alcohol dependence (moderate-severe alcohol use disorder)<br/></blockquote></div>"
},
"entry" : [
{
"reference" : "QuestionnaireResponse/e2fd5c67-c11d-4300-a113-8880116aba18"
}
]
},
{
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "30954-2",
"display" : "Lab diagnostic Report"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tbody><tr><th>Performed</th><th>Test</th><th>Conclusion</th></tr><tr><td><div><div>2024-07-01T12:25:35+08:00</div></div></td><td><div><div>Hemoglobin A1c/Hemoglobin.total (HbA1c)</div></div></td><td>7.2%</td></tr></tbody></table></div>"
},
"entry" : [
{
"reference" : "DiagnosticReport/urn:uuid:00000111-0001-0001-0003-000000000001"
}
]
}
]
}