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

: Example Composition discharge summary with multiple sections MyHix - TTL Representation

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@prefix fhir: <http://hl7.org/fhir/> .
@prefix loinc: <https://loinc.org/rdf/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .

# - resource -------------------------------------------------------------------

 a fhir:Composition ;
  fhir:nodeRole fhir:treeRoot ;
  fhir:id [ fhir:v "example-composition-hie-dc-comp-12345-140423"] ; # 
  fhir:meta [
fhir:lastUpdated [ fhir:v "2023-04-06T22:58:30.149+08:00"^^xsd:dateTime ] ;
fhir:source [ fhir:v "sample"^^xsd:anyURI ] ;
    ( fhir:profile [
fhir:v "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"^^xsd:anyURI ;
fhir:link <http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core>     ] ) ;
    ( fhir:security [
fhir:system [ fhir:v "http://terminology.hl7.org/CodeSystem/v3-Confidentiality"^^xsd:anyURI ] ;
fhir:code [ fhir:v "N" ]     ] )
  ] ; # 
  fhir:text [
fhir:status [ fhir:v "extensions" ] ;
fhir: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 TUANKU JA'AFAR, SEREMBAN</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 --&gt; (ongoing)</td></tr></table></div>"^^rdf:XMLLiteral
  ] ; # 
  fhir:extension ( [
fhir:url [ fhir:v "http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core"^^xsd:anyURI ] ;
fhir:value [
a fhir:Reference ;
fhir:display [ fhir:v "Ward A" ]     ]
  ] ) ; # 
  fhir:identifier [
fhir:system [ fhir:v "http://fhir.hie.moh.gov.my/sid/composition-id"^^xsd:anyURI ] ;
fhir:value [ fhir:v "HTJ-CMP-2304000003" ]
  ] ; # 
  fhir:status [ fhir:v "final"] ; # 
  fhir:type [
    ( fhir:coding [
fhir:system [ fhir:v "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core"^^xsd:anyURI ] ;
fhir:code [ fhir:v "18842-5" ] ;
fhir:display [ fhir:v "Discharge Summary Note" ]     ] )
  ] ; # 
  fhir:category ( [
    ( fhir:coding [
fhir:system [ fhir:v "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core"^^xsd:anyURI ] ;
fhir:code [ fhir:v "LP72467-1" ] ;
fhir:display [ fhir:v "Discharge Summary Note" ]     ] )
  ] ) ; # 
  fhir:subject [
fhir:reference [ fhir:v "Patient/patient-sample" ]
  ] ; # 
  fhir:encounter [
fhir:reference [ fhir:v "Encounter/encounter-sample" ]
  ] ; # 
  fhir:date [ fhir:v "2023-04-07T06:58:00.000+08:00"^^xsd:dateTime] ; # 
  fhir:author ( [
fhir:type [ fhir:v "PractitionerRole"^^xsd:anyURI ] ;
fhir:identifier [
fhir:system [ fhir:v "http://fhir.hie.moh.gov.my/sid/mmc-no"^^xsd:anyURI ] ;
fhir:value [ fhir:v "64325" ]     ] ;
fhir:display [ fhir:v "Saw Lee Chin" ]
  ] ) ; # 
  fhir:title [ fhir:v "Example Composition discharge summary with multiple sections MyHix"] ; # 
  fhir:attester ( [
fhir:mode [ fhir:v "professional" ] ;
fhir:time [ fhir:v "2023-04-07T06:58:00.000+08:00"^^xsd:dateTime ] ;
fhir:party [
fhir:type [ fhir:v "PractitionerRole"^^xsd:anyURI ] ;
fhir:identifier [
fhir:system [ fhir:v "http://fhir.hie.moh.gov.my/sid/nsr-no"^^xsd:anyURI ] ;
fhir:value [ fhir:v "23312" ]       ] ;
fhir:display [ fhir:v "Kamal Bin Arifin" ]     ]
  ] ) ; # 
  fhir:custodian [
fhir:reference [ fhir:v "Organization/11-05060009" ] ;
fhir:display [ fhir:v "HOSPITAL TUANKU JA'AFAR, SEREMBAN" ]
  ] ; # 
  fhir:event ( [
    ( fhir:code [
      ( fhir:coding [
fhir:system [ fhir:v "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core"^^xsd:anyURI ] ;
fhir:code [ fhir:v "18842-5" ] ;
fhir:display [ fhir:v "Discharge Summary Note" ]       ] )     ] ) ;
fhir:period [
fhir:start [ fhir:v "2023-04-07T06:57:00.000+08:00"^^xsd:dateTime ]     ]
  ] ) ; # 
  fhir:section ( [
fhir:title [ fhir:v "Clinical Information" ] ;
fhir:code [
      ( fhir:coding [
a loinc:55752-0 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "55752-0" ] ;
fhir:display [ fhir:v "Clinical Information" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><strong>Patient Name:</strong> Russell Johnson </p><p><strong>Medical Record Number:</strong> 123456789 </p><p><strong>Admission Date:</strong> 08 JAN 14 </p><p><strong>Discharge Date:</strong> 08 MAY 14 </p><p><strong>Attending Physician:</strong> Dr Gary Marshall </p><p><strong>Dictated by:</strong> Dr Gary Marhsall Primary </p><p><strong>Care Physician:</strong> Dr Dianna Miller Referring Physician: </p><p><strong>Consulting Physician(s):</strong> Dr Gary Marshall - hospitalist</p><p><strong>Condition on Discharge:</strong> stable </p><p><strong>Final Diagnosis: </strong></p><ol><li>RLL pneumonia</li><li>COPD exacerbation</li><li>mild CHF</li><li>osteoarthritis</li></ol><p><strong>Procedures:</strong> none </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. </p><ol><li>Pneumonia: treated with ceftriaxone and azithromycin iv. Switched to PO after 72 hours. </li><li>Exacerbation of COPD: patient treated with inhaled and oral steroids, O2 at 2l/nc. On RA at time of discharge </li><li>Weakness and dehydration: secondary to pneumonia and COPD. Responded well to strengthening with PT and regular meals. </li></ol><p><strong>Discharge Medications:</strong></p><p> Zithromycin daily until gone, inhalers #of puffs</p><p><strong>Discharge Instructions:</strong> no activity restriction, regular diet, follow up in two to three weeks with regular physician.</p></div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Problem list" ] ;
fhir:code [
      ( fhir:coding [
a loinc:11450-4 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "11450-4" ] ;
fhir:display [ fhir:v "Problem List" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">test%0A1%0A2%0A3</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Vital Sign" ] ;
fhir:code [
      ( fhir:coding [
a loinc:8716-3 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8716-3" ] ;
fhir:display [ fhir:v "Vital Sign" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Value:</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Respiratory Rate" ] ;
fhir:code [
      ( fhir:coding [
a loinc:9279-1 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "9279-1" ] ;
fhir:display [ fhir:v "Respiratory Rate" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Respiratory Rate: 80/min</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Heart Rate" ] ;
fhir:code [
      ( fhir:coding [
a loinc:8867-4 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8867-4" ] ;
fhir:display [ fhir:v "Heart Rate" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Heart Rate: 90/min</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Oxygen saturation" ] ;
fhir:code [
      ( fhir:coding [
a loinc:2708-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "2708-6" ] ;
fhir:display [ fhir:v "Oxygen Saturation" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Oxygen Saturation: 98@</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Body Temperature" ] ;
fhir:code [
      ( fhir:coding [
a loinc:8310-5 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8310-5" ] ;
fhir:display [ fhir:v "Body Temperature" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Body Temperature: 37'C</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Systolic Pressure" ] ;
fhir:code [
      ( fhir:coding [
a loinc:8480-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8480-6" ] ;
fhir:display [ fhir:v "Systolic Pressure" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Systolic Pressure: 120mmHg</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Diastolic Pressure" ] ;
fhir:code [
      ( fhir:coding [
a loinc:8462-4 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "8462-4" ] ;
fhir:display [ fhir:v "Diastolic Pressure" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Diastolic Pressure: 90mmHg</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Pain Score" ] ;
fhir:code [
      ( fhir:coding [
a loinc:72514-3 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "72514-3" ] ;
fhir:display [ fhir:v "Pain Score" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pain Score: 4</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Allergies And Intolerance" ] ;
fhir:code [
      ( fhir:coding [
a loinc:48765-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "48765-2" ] ;
fhir:display [ fhir:v "Allergies And Intolerance" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Patient allergic to:</p><p>1. Paracetamol</p><p>2. Peanut</p></div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Medication" ] ;
fhir:code [
      ( fhir:coding [
a loinc:10160-0 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "10160-0" ] ;
fhir:display [ fhir:v "Medication" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir: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>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Social History" ] ;
fhir:code [
      ( fhir:coding [
a loinc:29762-2 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "29762-2" ] ;
fhir:display [ fhir:v "Social History" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">social%20history%20goes%20here%0A1%0A2%0A3</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Family History" ] ;
fhir:code [
      ( fhir:coding [
a loinc:10157-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "10157-6" ] ;
fhir:display [ fhir:v "Family History" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">family%20history%20goes%20here%0A1%0A2%0A3</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Immunization History" ] ;
fhir:code [
      ( fhir:coding [
a loinc:11369-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "11369-6" ] ;
fhir:display [ fhir:v "Immunization History" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">immunization%20hx%20goes%20here%0A1%0A2%0A3</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Assessment" ] ;
fhir:code [
      ( fhir:coding [
a loinc:51848-0 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "51848-0" ] ;
fhir:display [ fhir:v "Assessment" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir: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 &amp; Reported By: Siti Zarinawati Binti Johari (Juruteknologi Makmal Perubatan U29)<br/>Validated On: 11 OCT 2022 14:53:54<br/>Accessed &amp; 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>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Care Plan" ] ;
fhir:code [
      ( fhir:coding [
a loinc:18776-5 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "18776-5" ] ;
fhir:display [ fhir:v "Care Plan" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">care%20plan%20goes%20here%0A1%0A2%0A3</div>"^^rdf:XMLLiteral     ]
  ] [
fhir:title [ fhir:v "Adverse Event" ] ;
fhir:code [
      ( fhir:coding [
a loinc:85893-6 ;
fhir:system [ fhir:v "http://loinc.org"^^xsd:anyURI ] ;
fhir:code [ fhir:v "85893-6" ] ;
fhir:display [ fhir:v "Adverse Event" ]       ] )     ] ;
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir:div "<div xmlns=\"http://www.w3.org/1999/xhtml\">adverse%20event%20goe%20shere%0A1%0A2%0A3</div>"^^rdf:XMLLiteral     ]
  ] ) . #