HL7 FHIR Malaysia Core (MY Core) Implementation Guide
2.0.0 - ci-build
HL7 FHIR Malaysia Core (MY Core) Implementation Guide - Local Development build (v2.0.0) 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"/>
<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</b></p><a name="example-composition-myhix"> </a><a name="hcexample-composition-myhix"> </a><a name="example-composition-myhix-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 with single section 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 with single section 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>Allergies</strong></h2><ul><li><strong>Allergies and Other Adverse Reactions:</strong><p>Patient allergic to:</p><p>1. Paracetamol</p><p>2. Peanut</p></li></ul><h2><strong>Reason for Care</strong></h2><ul><li><strong>Hospital Admission Diagnosis:</strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li></ol></li><li><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></li></ul><h2><strong>Other Condition Histories</strong></h2><ul><li><strong><strong>Active Problems:</strong></strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li><li>mild CHF</li><li>osteoarthritis</li></ol></li><li><strong>Discharge Diagnosis:</strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li><li>mild CHF</li><li>osteoarthritis</li></ol></li><li><strong>Resolved Problems:</strong> none</li><li><strong>List of Surgeries:</strong><ol><li>Craniotomy</li><li>Lumbar Puncture</li></ol></li></ul><h2><strong>Medication</strong></h2><ul><li><strong>Medications: </strong>Zithromycin daily until gone, inhalers #of puffs</li></ul><h2><strong>Relevant Studies</strong></h2><ul><li><strong>Results:</strong> </li></ul><p>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</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><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><ul><li><strong>Hospital Discharge:</strong> none</li><li><strong>Studies Summary:</strong> none</li></ul><h2><strong>Plans of Care</strong></h2><ul><li><strong>Care Plan: </strong>No activity restriction, regular diet, follow up in two to three weeks with regular physician.</li></ul></div>
</text>
</section>
</Composition>