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
<Composition xmlns="http://hl7.org/fhir">
<id value="example-composition-health-screening-nhsi"/>
<meta>
<source value="http://example.com"/>
<profile
value="http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"/>
<profile
value="http://fhir.hie.moh.gov.my/StructureDefinition/Composition-health-screening-my-core"/>
</meta>
<text>
<status value="generated"/>
<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>
</text>
<identifier>
<value value="hs-123"/>
</identifier>
<status value="final"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="64285-0"/>
<display value="Medical history screening form"/>
</coding>
</type>
<category>
<coding>
<system value="http://loinc.org"/>
<code value="LP199484-9"/>
<display value="Form"/>
</coding>
</category>
<subject>
<reference value="Patient/patient-placeholder"/>
</subject>
<encounter>
<reference value="Encounter/1ed9f4c0-69a9-4cf3-abd7-27d27943ee3d"/>
</encounter>
<date value="2024-07-18T08:00:00+08:00"/>
<author>
<type value="PractitionerRole"/>
<display value="Saifuldaulah Bin Mohd Hafiz Ngoo"/>
</author>
<title value="Example Composition NHSI health screening"/>
<confidentiality value="N"/>
<custodian>
<reference value="Organization/11-05060009"/>
</custodian>
<event>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="64285-0"/>
<display value="Medical history screening form"/>
</coding>
</code>
<period>
<start value="2024-07-18T08:00:00+08:00"/>
</period>
</event>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11450-4"/>
<display value="Problem list"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference value="Condition/ca211a37-a7b9-42f7-a853-70cbb2f8f295"/>
</entry>
<entry>
<reference value="Condition/3051480c-2a46-4818-b4dc-57de6159e3d8"/>
</entry>
<entry>
<reference value="Condition/bb5460e7-cf4e-4799-8724-07f531dfa984"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="8716-3"/>
<display value="Vital Signs"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference
value="Observation/urn:uuid:00000011-0001-0001-0003-000000000001"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="55418-8"/>
<display value="Anthropometry"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference
value="Observation/urn:uuid:00000011-0001-0001-0004-000000000001"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="72166-2"/>
<display value="Smoking History"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference value="Observation/f1ac639e-052f-4d2f-a7dc-ebb6eb0334f2"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="74013-4"/>
<display value="Alcohol Use History"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference
value="QuestionnaireResponse/e2fd5c67-c11d-4300-a113-8880116aba18"/>
</entry>
</section>
<section>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="30954-2"/>
<display value="Lab diagnostic Report"/>
</coding>
</code>
<text>
<status value="generated"/>
<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>
</text>
<entry>
<reference
value="DiagnosticReport/urn:uuid:00000111-0001-0001-0003-000000000001"/>
</entry>
</section>
</Composition>