HL7® FHIR® Malaysia Core (MY Core) Implementation Guide
2.0.1 - ci-build

HL7® FHIR® Malaysia Core (MY Core) Implementation Guide - Local Development build (v2.0.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example Procedure: Example Procedure

version: 2; Last updated: 2022-09-07 09:04:34+0800;

Information Source: http://provider.hie.moh.gov.my

Profile: Procedure (MY Core)

status: Completed

category: Surgical procedure

code: Operations on chest wall, pleura, mediastinum, and diaphragm

​subject: Patient/f92c383f-68de-46c1-8cde-970efa2d0f15

​encounter: Encounter/5579c35d-97af-463a-b4d7-df2d9e3dc267

performed: 2022-06-28 15:30:00+0800 --> 2022-06-28 18:00:00+0800

​recorder: PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba

​asserter: PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f

performer

function: Accident and emergency doctor

​actor: PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f

​onBehalfOf: Organization/11-05040012

performer

function: House officer

​actor: PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba

​onBehalfOf: Organization/11-05060009

​location: Location/8d988a14-4e08-4b57-a6d2-323218dcb76e

bodySite: Left thorax structure

outcome: Successful

complication: Complication 1, Complication 2

note: By PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba @2022-06-28 18:00:00+0800, By PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f @2022-06-28 18:10:00+0800

<div xmlns="http://www.w3.org/1999/xhtml">Procedure: Left chest tube insertion. Indication: Left lung hemothorax post MVA

  • Explained to patient procedure indication and complication. Patient understood and agreed
  • Positioned patient in a lying supine position with left arm above the head
  • Placed the patient on the cardiac monitor, pulse oximetry and supplemental oxygen
  • 2 large 16G bore cannula secured
  • Safety triangle landmark identified, cleaned and draped
  • Chest tube 22fr prepared and clamped with Kelly clamp
  • LA 10ml given around incision area
  • 3cm incision done between 4th and 5th rib intercostal space, mid axillary line
  • Kelly clamp used to bluntly dissect the underlying subcutaneous tissue muscle until left lung pleura reached
  • Index finger inserted into incision and used to sweep inside left chest cavity
  • chests tube size 22fr inserted with index finger guidance and chest tube connected to functioning underwater seal
  • incision site cleaned and chest tube secured with Prolene 1 purse-string suture.</div>

<div xmlns="http://www.w3.org/1999/xhtml">Keep left chest tube in secured monitor VS every 30m, keep BP > 120/90 Continue NP 3L/min Provide adequate analgesia Send for repeat chest PA once patient more conscious Trace CT brain preliminary report Update surgical team on finding, push for admission once patient return from X-ray</div>

usedCode: Silk suture, Forceps, Cannula, tube AND/OR catheter