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-myhix-template"/>
<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-myhix-template</b></p><a name="example-composition-myhix-template"> </a><a name="hcexample-composition-myhix-template"> </a><a name="example-composition-myhix-template-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-Hix-2304000001</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 template 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 --> (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-Hix-2304000001"/>
</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 template 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"><h2><strong>Document Set</strong></h2><ul><li><strong>Document unique id: </strong>entry goes here</li><li><strong>Document repository unique id:</strong> entry goes here</li><li><strong>Document title:</strong> entry goes here</li><li><strong>Document confidentiality:</strong> entry goes here</li><li><strong>Document creation time:</strong> entry goes here</li><li><strong>Parent document id:</strong> entry goes here</li><li><strong>Parent document relationship:</strong> entry goes here</li></ul><h2><strong>Custodian</strong></h2><ul><li><strong>OID:</strong> entry goes here</li><li><strong>Name:</strong> entry goes here</li><li><strong>Address:</strong> entry goes here</li></ul><h2><strong>Patient</strong></h2><ul><li><strong>Name:</strong> entry goes here</li><li><strong>Gender:</strong> entry goes here</li><li><strong>DOB:</strong> entry goes here</li><li><strong>Race:</strong> entry goes here</li><li><strong>MRN:</strong> entry goes here</li><li><strong>Address:</strong> entry goes here</li><li><strong>Phone home:</strong> entry goes here</li><li><strong>Phone office:</strong> entry goes here</li><li><strong>Fax:</strong> entry goes here</li><li><strong>Email address:</strong> entry goes here</li><li><strong>National id:</strong> entry goes here</li></ul><h2><strong>Author</strong></h2><ul><li><strong>Name:</strong> entry goes here</li><li><strong>MMC:</strong> entry goes here</li><li><strong>Facility OID:</strong> entry goes here</li><li><strong>Facility name:</strong> entry goes here</li><li><strong>Time:</strong> entry goes here</li></ul><h2><strong>Consultant</strong></h2><ul><li><strong>Name:</strong> entry goes here</li><li><strong>MMC:</strong> entry goes here</li><li><strong>NSR:</strong> entry goes here</li><li><strong>Facility OID:</strong> entry goes here</li><li><strong>Facility name:</strong> entry goes here</li><li><strong>Time:</strong> entry goes here</li></ul><h2><strong>Visit / EncounterAdmission date</strong></h2><ul><li><strong>Discharge date:</strong> entry goes here</li><li><strong>Visit id:</strong> entry goes here</li><li><strong>Time:</strong> entry goes here</li><li><strong>Assign doctor name:</strong> entry goes here</li><li><strong>Assign doctor:</strong> entry goes here</li><li><strong>MMC:</strong> entry goes here</li><li><strong>Assign doctor facility OID:</strong> entry goes here</li><li><strong>Assign doctor facility name: </strong>entry goes here</li><li><strong>Service id: </strong>entry goes here</li><li><strong>Service name: </strong>entry goes here</li></ul><h2><strong>Allergies</strong></h2><ul><li><strong>Allergies and Other Adverse Reactions:</strong> entry goes here</li></ul><h2><strong>Reason for Care</strong></h2><ul><li><strong>Hospital Admission Diagnosis:</strong> entry goes here</li></ul><h2><strong>Other Condition Histories</strong></h2><ul><li><strong>Active Problems:</strong> entry goes here</li><li><strong>Discharge Diagnosis:</strong> entry goes here</li><li><strong>Resolved Problems:</strong> entry goes here</li><li><strong>List of Surgeries:</strong> entry goes here</li></ul><h2><strong>Medication</strong></h2><ul><li><strong>Medications: entry goes here</strong></li></ul><h2><strong>Relevant Studies</strong></h2><ul><li><strong>Results:</strong> entry goes here</li><li><strong>Hospital Discharge:</strong> entry goes here</li><li><strong>Studies Summary:</strong> entry goes here</li></ul><h2><strong>Plans of Care</strong></h2><ul><li><strong>Care Plan: </strong>entry goes here</li></ul><h2><strong>Correspondence Facility</strong></h2><ul><li><strong>OID:</strong> entry goes here</li><li><strong>NameAddress:</strong> entry goes here</li></ul></div>
</text>
</section>
</Composition>