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

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

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<Composition xmlns="http://hl7.org/fhir">
  <id value="example-composition-hie-dc-comp-12345-140423"/>
  <meta>
    <lastUpdated value="2023-04-06T22:58:30.149+08:00"/>
    <source value="sample"/>
    <profile
             value="http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"/>
    <security>
      <system
              value="http://terminology.hl7.org/CodeSystem/v3-Confidentiality"/>
      <code value="N"/>
    </security>
  </meta>
  <text>
    <status value="extensions"/>
    <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>
  </text>
  <extension
             url="http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core">
    <valueReference>
      <display value="Ward A"/>
    </valueReference>
  </extension>
  <identifier>
    <system value="http://fhir.hie.moh.gov.my/sid/composition-id"/>
    <value value="HTJ-CMP-2304000003"/>
  </identifier>
  <status value="final"/>
  <type>
    <coding>
      <system
              value="http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core"/>
      <code value="18842-5"/>
      <display value="Discharge Summary Note"/>
    </coding>
  </type>
  <category>
    <coding>
      <system
              value="http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core"/>
      <code value="LP72467-1"/>
      <display value="Discharge Summary Note"/>
    </coding>
  </category>
  <subject>
    <reference value="Patient/patient-sample"/>
  </subject>
  <encounter>
    <reference value="Encounter/encounter-sample"/>
  </encounter>
  <date value="2023-04-07T06:58:00.000+08:00"/>
  <author>
    <type value="PractitionerRole"/>
    <identifier>
      <system value="http://fhir.hie.moh.gov.my/sid/mmc-no"/>
      <value value="64325"/>
    </identifier>
    <display value="Saw Lee Chin"/>
  </author>
  <title
         value="Example Composition discharge summary with multiple sections MyHix"/>
  <attester>
    <mode value="professional"/>
    <time value="2023-04-07T06:58:00.000+08:00"/>
    <party>
      <type value="PractitionerRole"/>
      <identifier>
        <system value="http://fhir.hie.moh.gov.my/sid/nsr-no"/>
        <value value="23312"/>
      </identifier>
      <display value="Kamal Bin Arifin"/>
    </party>
  </attester>
  <custodian>
    <reference value="Organization/11-05060009"/>
    <display value="HOSPITAL TUANKU JA'AFAR, SEREMBAN"/>
  </custodian>
  <event>
    <code>
      <coding>
        <system
                value="http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core"/>
        <code value="18842-5"/>
        <display value="Discharge Summary Note"/>
      </coding>
    </code>
    <period>
      <start value="2023-04-07T06:57:00.000+08:00"/>
    </period>
  </event>
  <section>
    <title value="Clinical Information"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="55752-0"/>
        <display value="Clinical Information"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  </section>
  <section>
    <title value="Problem list"/>
    <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">test%0A1%0A2%0A3</div>
    </text>
  </section>
  <section>
    <title value="Vital Sign"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8716-3"/>
        <display value="Vital Sign"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Value:</div>
    </text>
  </section>
  <section>
    <title value="Respiratory Rate"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="9279-1"/>
        <display value="Respiratory Rate"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Respiratory Rate: 80/min</div>
    </text>
  </section>
  <section>
    <title value="Heart Rate"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8867-4"/>
        <display value="Heart Rate"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Heart Rate: 90/min</div>
    </text>
  </section>
  <section>
    <title value="Oxygen saturation"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="2708-6"/>
        <display value="Oxygen Saturation"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Oxygen Saturation: 98@</div>
    </text>
  </section>
  <section>
    <title value="Body Temperature"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8310-5"/>
        <display value="Body Temperature"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Body Temperature: 37'C</div>
    </text>
  </section>
  <section>
    <title value="Systolic Pressure"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8480-6"/>
        <display value="Systolic Pressure"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Systolic Pressure: 120mmHg</div>
    </text>
  </section>
  <section>
    <title value="Diastolic Pressure"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="8462-4"/>
        <display value="Diastolic Pressure"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Diastolic Pressure: 90mmHg</div>
    </text>
  </section>
  <section>
    <title value="Pain Score"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="72514-3"/>
        <display value="Pain Score"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">Pain Score: 4</div>
    </text>
  </section>
  <section>
    <title value="Allergies And Intolerance"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="48765-2"/>
        <display value="Allergies And Intolerance"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml"><p>Patient allergic to:</p><p>1. Paracetamol</p><p>2. Peanut</p></div>
    </text>
  </section>
  <section>
    <title value="Medication"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10160-0"/>
        <display value="Medication"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  </section>
  <section>
    <title value="Social History"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="29762-2"/>
        <display value="Social History"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">social%20history%20goes%20here%0A1%0A2%0A3</div>
    </text>
  </section>
  <section>
    <title value="Family History"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="10157-6"/>
        <display value="Family History"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">family%20history%20goes%20here%0A1%0A2%0A3</div>
    </text>
  </section>
  <section>
    <title value="Immunization History"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="11369-6"/>
        <display value="Immunization History"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">immunization%20hx%20goes%20here%0A1%0A2%0A3</div>
    </text>
  </section>
  <section>
    <title value="Assessment"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="51848-0"/>
        <display value="Assessment"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <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>
    </text>
  </section>
  <section>
    <title value="Care Plan"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="18776-5"/>
        <display value="Care Plan"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">care%20plan%20goes%20here%0A1%0A2%0A3</div>
    </text>
  </section>
  <section>
    <title value="Adverse Event"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="85893-6"/>
        <display value="Adverse Event"/>
      </coding>
    </code>
    <text>
      <status value="generated"/>
      <div xmlns="http://www.w3.org/1999/xhtml">adverse%20event%20goe%20shere%0A1%0A2%0A3</div>
    </text>
  </section>
</Composition>