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-hie-dc-comp-12345-140423",
"meta" : {
"lastUpdated" : "2023-04-06T22:58:30.149+08:00",
"source" : "sample",
"profile" : [
🔗 "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"
],
"security" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
"code" : "N"
}
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"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Composition example-composition-hie-dc-comp-12345-140423</b></p><a name=\"example-composition-hie-dc-comp-12345-140423\"> </a><a name=\"hcexample-composition-hie-dc-comp-12345-140423\"> </a><a name=\"example-composition-hie-dc-comp-12345-140423-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\">Last updated: 2023-04-06 22:58:30+0800; </p><p style=\"margin-bottom: 0px\">Information Source: sample</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-Composition-my-core.html\">Composition (MY Core)</a></p><p style=\"margin-bottom: 0px\">Security Label: normal (Details: Confidentiality code N = 'normal')</p></div><p><b>ExtensionLocationRecorded (MY Core)</b>: Ward A</p><p><b>identifier</b>: <code>http://fhir.hie.moh.gov.my/sid/composition-id</code>/HTJ-CMP-2304000003</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core 18842-5}\">Discharge Summary Note</span></p><p><b>category</b>: <span title=\"Codes:{http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core LP72467-1}\">Discharge Summary Note</span></p><p><b>encounter</b>: <a href=\"Bundle-example-bundle-encounter-summary.html#Encounter_encounter-sample\">Bundle: type = transaction</a></p><p><b>date</b>: 2023-04-07 06:58:00+0800</p><p><b>author</b>: Saw Lee Chin (Identifier: <code>http://fhir.hie.moh.gov.my/sid/mmc-no</code>/64325)</p><p><b>title</b>: Example Composition discharge summary with multiple sections MyHix</p><h3>Attesters</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Mode</b></td><td><b>Time</b></td><td><b>Party</b></td></tr><tr><td style=\"display: none\">*</td><td>Professional</td><td>2023-04-07 06:58:00+0800</td><td>Kamal Bin Arifin (Identifier: <code>http://fhir.hie.moh.gov.my/sid/nsr-no</code>/23312)</td></tr></table><p><b>custodian</b>: <a href=\"Organization/11-05060009\">HOSPITAL\u00a0TUANKU\u00a0JA'AFAR,\u00a0SEREMBAN</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://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core 18842-5}\">Discharge Summary Note</span></td><td>2023-04-07 06:57:00+0800 --> (ongoing)</td></tr></table></div>"
},
"extension" : [
{
"url" : "http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core",
"valueReference" : {
"display" : "Ward A"
}
}
],
"identifier" : {
"system" : "http://fhir.hie.moh.gov.my/sid/composition-id",
"value" : "HTJ-CMP-2304000003"
},
"status" : "final",
"type" : {
"coding" : [
{
"system" : "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core",
"code" : "18842-5",
"display" : "Discharge Summary Note"
}
]
},
"category" : [
{
"coding" : [
{
"system" : "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core",
"code" : "LP72467-1",
"display" : "Discharge Summary Note"
}
]
}
],
"subject" : {
"reference" : "Patient/patient-sample"
},
"encounter" : {
"reference" : "Encounter/encounter-sample"
},
"date" : "2023-04-07T06:58:00.000+08:00",
"author" : [
{
"type" : "PractitionerRole",
"identifier" : {
"system" : "http://fhir.hie.moh.gov.my/sid/mmc-no",
"value" : "64325"
},
"display" : "Saw Lee Chin"
}
],
"title" : "Example Composition discharge summary with multiple sections MyHix",
"attester" : [
{
"mode" : "professional",
"time" : "2023-04-07T06:58:00.000+08:00",
"party" : {
"type" : "PractitionerRole",
"identifier" : {
"system" : "http://fhir.hie.moh.gov.my/sid/nsr-no",
"value" : "23312"
},
"display" : "Kamal Bin Arifin"
}
}
],
"custodian" : {
"reference" : "Organization/11-05060009",
"display" : "HOSPITAL\u00a0TUANKU\u00a0JA'AFAR,\u00a0SEREMBAN"
},
"event" : [
{
"code" : [
{
"coding" : [
{
"system" : "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core",
"code" : "18842-5",
"display" : "Discharge Summary Note"
}
]
}
],
"period" : {
"start" : "2023-04-07T06:57:00.000+08:00"
}
}
],
"section" : [
{
"title" : "Clinical Information",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "55752-0",
"display" : "Clinical Information"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><strong>Patient Name:</strong>\u00a0Russell Johnson\u00a0</p><p><strong>Medical Record Number:</strong>\u00a0123456789\u00a0</p><p><strong>Admission Date:</strong>\u00a008 JAN 14\u00a0</p><p><strong>Discharge Date:</strong>\u00a008 MAY 14\u00a0</p><p><strong>Attending Physician:</strong>\u00a0Dr Gary Marshall\u00a0</p><p><strong>Dictated by:</strong>\u00a0Dr Gary Marhsall Primary\u00a0</p><p><strong>Care Physician:</strong>\u00a0Dr Dianna Miller Referring Physician:\u00a0</p><p><strong>Consulting Physician(s):</strong>\u00a0Dr Gary Marshall - hospitalist</p><p><strong>Condition on\u00a0Discharge:</strong>\u00a0stable\u00a0</p><p><strong>Final Diagnosis:\u00a0</strong></p><ol><li>RLL pneumonia</li><li>COPD exacerbation</li><li>mild CHF</li><li>osteoarthritis</li></ol><p><strong>Procedures:</strong>\u00a0none\u00a0</p><p><strong>History of Present Illness</strong></p><p>72 year old thin white male presented to emergency on 8 JAN 14 with shortness of breath, weakness and dehydration. Chest X-ray showed right lower lobe infiltrate, ABGs unremarkable. Pulse ox on RA was 79%25.\u00a0</p><ol><li>Pneumonia: treated with ceftriaxone and azithromycin iv. Switched to PO after 72 hours.\u00a0</li><li>Exacerbation of COPD: patient treated with inhaled and oral steroids, O2 at 2l/nc. On RA at time of discharge\u00a0</li><li>Weakness and dehydration: secondary to pneumonia and COPD. Responded well to strengthening with PT and regular meals.\u00a0</li></ol><p><strong>Discharge Medications:</strong></p><p>\u00a0Zithromycin daily until gone, inhalers #of puffs</p><p><strong>Discharge Instructions:</strong>\u00a0no activity restriction, regular diet, follow up in two to three weeks with regular physician.</p></div>"
}
},
{
"title" : "Problem list",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11450-4",
"display" : "Problem List"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">test%0A1%0A2%0A3</div>"
}
},
{
"title" : "Vital Sign",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8716-3",
"display" : "Vital Sign"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Value:</div>"
}
},
{
"title" : "Respiratory Rate",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "9279-1",
"display" : "Respiratory Rate"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Respiratory Rate: 80/min</div>"
}
},
{
"title" : "Heart Rate",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8867-4",
"display" : "Heart Rate"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Heart Rate: 90/min</div>"
}
},
{
"title" : "Oxygen saturation",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "2708-6",
"display" : "Oxygen Saturation"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Oxygen Saturation: 98@</div>"
}
},
{
"title" : "Body Temperature",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8310-5",
"display" : "Body Temperature"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Body Temperature: 37'C</div>"
}
},
{
"title" : "Systolic Pressure",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8480-6",
"display" : "Systolic Pressure"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Systolic Pressure: 120mmHg</div>"
}
},
{
"title" : "Diastolic Pressure",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "8462-4",
"display" : "Diastolic Pressure"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Diastolic Pressure: 90mmHg</div>"
}
},
{
"title" : "Pain Score",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "72514-3",
"display" : "Pain Score"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pain Score: 4</div>"
}
},
{
"title" : "Allergies And Intolerance",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "48765-2",
"display" : "Allergies And Intolerance"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Patient allergic to:</p><p>1. Paracetamol</p><p>2. Peanut</p></div>"
}
},
{
"title" : "Medication",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10160-0",
"display" : "Medication"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Patient home medication:</p><p>1. T PCM 500mg PRN</p><p>2. T metformin 500mg BD</p><p>3. T amlodipine 10mg OD</p></div>"
}
},
{
"title" : "Social History",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "29762-2",
"display" : "Social History"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">social%20history%20goes%20here%0A1%0A2%0A3</div>"
}
},
{
"title" : "Family History",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "10157-6",
"display" : "Family History"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">family%20history%20goes%20here%0A1%0A2%0A3</div>"
}
},
{
"title" : "Immunization History",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "11369-6",
"display" : "Immunization History"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">immunization%20hx%20goes%20here%0A1%0A2%0A3</div>"
}
},
{
"title" : "Assessment",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "51848-0",
"display" : "Assessment"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Name : MUHAMAD LUTHFI BIN HAZLAMI<br/>Sample : 11 OCT 2022 11:48:16<br/>IC/Passport : 201110101859<br/>Doctor : DR NURUL FAUZAN BIN MOHD PAUZI<br/>Registration : 11 OCT 2022 11:48:16 D.O.B. : 10 NOV 2020<br/>Clinic : KLINIK PAKAR<br/>Completion : 11 OCT 2022 14:53:54<br/>Age : 1 YEAR 11 MTH<br/>Gender : MALE</p><p>Validated & Reported By: Siti Zarinawati Binti Johari (Juruteknologi Makmal Perubatan U29)<br/>Validated On: 11 OCT 2022 14:53:54<br/>Accessed & Printed By: (10.29.194.218) Accessed On: 11 OCT 2022, 17:26:13</p><br/><table><tbody><tr><th>Full Blood Count</th><th>Result</th><th>Unit</th><th>Ref Range</th></tr><tr><td>White Blood Cell Count</td><td>H 16.97</td><td>x 10^3uL</td><td>( 4.078 - 11.370 )</td></tr><tr><td>Red Blood Cell Count</td><td>L 3.85</td><td>x 10^6uL</td><td>( 4.53 - 5.95 )</td></tr><tr><td>Haemoglobin</td><td>LL 6.7</td><td>g/dL</td><td>( 13.5 - 17.4 )</td></tr><tr><td>Hematocrit</td><td>L 20.5</td><td>%25</td><td>( 40.1 - 50.6 )</td></tr><tr><td>Mean Cell Volume</td><td>L 53.2</td><td>fL</td><td>( 80.6 - 95.5 )</td></tr><tr><td>Mean Cell Haemoglobin</td><td>L 17.4</td><td>pg</td><td>( 26.9 - 32.3 )</td></tr><tr><td>Mean Cell Haemoglobin Concentration</td><td>32.7</td><td>g/dL</td><td>( 31.9 - 35.3 )</td></tr></tbody></table></div>"
}
},
{
"title" : "Care Plan",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "18776-5",
"display" : "Care Plan"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">care%20plan%20goes%20here%0A1%0A2%0A3</div>"
}
},
{
"title" : "Adverse Event",
"code" : {
"coding" : [
{
"system" : "http://loinc.org",
"code" : "85893-6",
"display" : "Adverse Event"
}
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">adverse%20event%20goe%20shere%0A1%0A2%0A3</div>"
}
}
]
}