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
{
"resourceType" : "Procedure",
"id" : "example-procedure",
"meta" : {
"versionId" : "2",
"lastUpdated" : "2022-09-07T09:04:34.378+08:00",
"source" : "http://provider.hie.moh.gov.my",
"profile" : [
🔗 "http://fhir.hie.moh.gov.my/StructureDefinition/Procedure-my-core"
]
},
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Procedure example-procedure</b></p><a name=\"example-procedure\"> </a><a name=\"hcexample-procedure\"> </a><a name=\"example-procedure-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\">version: 2; Last updated: 2022-09-07 09:04:34+0800; </p><p style=\"margin-bottom: 0px\">Information Source: <a href=\"http://provider.hie.moh.gov.my\">http://provider.hie.moh.gov.my</a></p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-Procedure-my-core.html\">Procedure (MY Core)</a></p></div><p><b>status</b>: Completed</p><p><b>category</b>: <span title=\"Codes:{http://snomed.info/sct 387713003}\">Surgical procedure</span></p><p><b>code</b>: <span title=\"Codes:{http://fhir.hie.moh.gov.my/CodeSystem/procedure-code-my-core 34}\">Operations on chest wall, pleura, mediastinum, and diaphragm</span></p><p><b>subject</b>: <a href=\"Patient/f92c383f-68de-46c1-8cde-970efa2d0f15\">Patient/f92c383f-68de-46c1-8cde-970efa2d0f15</a></p><p><b>encounter</b>: <a href=\"Encounter/5579c35d-97af-463a-b4d7-df2d9e3dc267\">Encounter/5579c35d-97af-463a-b4d7-df2d9e3dc267</a></p><p><b>performed</b>: 2022-06-28 15:30:00+0800 --> 2022-06-28 18:00:00+0800</p><p><b>recorder</b>: <a href=\"PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba\">PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba</a></p><p><b>asserter</b>: <a href=\"PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f\">PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f</a></p><blockquote><p><b>performer</b></p><p><b>function</b>: <span title=\"Codes:{http://snomed.info/sct 309294001}\">Accident and emergency doctor</span></p><p><b>actor</b>: <a href=\"PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f\">PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f</a></p><p><b>onBehalfOf</b>: <a href=\"Organization/11-05040012\">Organization/11-05040012</a></p></blockquote><blockquote><p><b>performer</b></p><p><b>function</b>: <span title=\"Codes:{http://snomed.info/sct 158972004}\">House officer</span></p><p><b>actor</b>: <a href=\"PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba\">PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba</a></p><p><b>onBehalfOf</b>: <a href=\"Organization/11-05060009\">Organization/11-05060009</a></p></blockquote><p><b>location</b>: <a href=\"Location/8d988a14-4e08-4b57-a6d2-323218dcb76e\">Location/8d988a14-4e08-4b57-a6d2-323218dcb76e</a></p><p><b>bodySite</b>: <span title=\"Codes:\">Left thorax structure</span></p><p><b>outcome</b>: <span title=\"Codes:{http://snomed.info/sct 385669000}\">Successful</span></p><p><b>complication</b>: <span title=\"Codes:\">Complication 1</span>, <span title=\"Codes:\">Complication 2</span></p><p><b>note</b>: <div xmlns="http://www.w3.org/1999/xhtml">Procedure: Left chest tube insertion.\nIndication: Left lung hemothorax post MVA\n\n- Explained to patient procedure indication and complication. Patient understood and agreed\n- Positioned patient in a lying supine position with left arm above the head\n- Placed the patient on the cardiac monitor, pulse oximetry and supplemental oxygen\n- 2 large 16G bore cannula secured \n- Safety triangle landmark identified, cleaned and draped\n- Chest tube 22fr prepared and clamped with Kelly clamp\n- LA 10ml given around incision area\n- 3cm incision done between 4th and 5th rib intercostal space, mid axillary line\n- Kelly clamp used to bluntly dissect the underlying subcutaneous tissue muscle until left lung pleura reached\n- Index finger inserted into incision and used to sweep inside left chest cavity\n- chests tube size 22fr inserted with index finger guidance and chest tube connected to functioning underwater seal\n- incision site cleaned and chest tube secured with Prolene 1 purse-string suture.</div> (By PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba @2022-06-28 18:00:00+0800), <div xmlns="http://www.w3.org/1999/xhtml">Keep left chest tube in secured\nmonitor VS every 30m, keep BP &gt; 120/90\nContinue NP 3L/min\nProvide adequate analgesia\nSend for repeat chest PA once patient more conscious\nTrace CT brain preliminary report\nUpdate surgical team on finding, push for admission once patient return from X-ray</div> (By PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f @2022-06-28 18:10:00+0800)</p><p><b>usedCode</b>: <span title=\"Codes:\">Silk suture</span>, <span title=\"Codes:\">Forceps</span>, <span title=\"Codes:\">Cannula, tube AND/OR catheter</span></p></div>"
},
"status" : "completed",
"category" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "387713003",
"display" : "Surgical procedure"
}
]
},
"code" : {
"coding" : [
{
"system" : "http://fhir.hie.moh.gov.my/CodeSystem/procedure-code-my-core",
"code" : "34",
"display" : "Operations on chest wall, pleura, mediastinum, and diaphragm"
}
]
},
"subject" : {
"reference" : "Patient/f92c383f-68de-46c1-8cde-970efa2d0f15"
},
"encounter" : {
"reference" : "Encounter/5579c35d-97af-463a-b4d7-df2d9e3dc267"
},
"performedPeriod" : {
"start" : "2022-06-28T15:30:00.000+08:00",
"end" : "2022-06-28T18:00:00.000+08:00"
},
"recorder" : {
"reference" : "PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba"
},
"asserter" : {
"reference" : "PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f"
},
"performer" : [
{
"function" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "309294001",
"display" : "Accident and emergency doctor"
}
]
},
"actor" : {
"reference" : "PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f"
},
"onBehalfOf" : {
"reference" : "Organization/11-05040012"
}
},
{
"function" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "158972004",
"display" : "House officer"
}
]
},
"actor" : {
"reference" : "PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba"
},
"onBehalfOf" : {
"reference" : "Organization/11-05060009"
}
}
],
"location" : {
"reference" : "Location/8d988a14-4e08-4b57-a6d2-323218dcb76e"
},
"bodySite" : [
{
"text" : "Left thorax structure"
}
],
"outcome" : {
"coding" : [
{
"system" : "http://snomed.info/sct",
"code" : "385669000",
"display" : "Successful"
}
]
},
"complication" : [
{
"text" : "Complication 1"
},
{
"text" : "Complication 2"
}
],
"note" : [
{
"authorReference" : {
"reference" : "PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba"
},
"time" : "2022-06-28T18:00:00.000+08:00",
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Procedure: Left chest tube insertion.\nIndication: Left lung hemothorax post MVA\n\n- Explained to patient procedure indication and complication. Patient understood and agreed\n- Positioned patient in a lying supine position with left arm above the head\n- Placed the patient on the cardiac monitor, pulse oximetry and supplemental oxygen\n- 2 large 16G bore cannula secured \n- Safety triangle landmark identified, cleaned and draped\n- Chest tube 22fr prepared and clamped with Kelly clamp\n- LA 10ml given around incision area\n- 3cm incision done between 4th and 5th rib intercostal space, mid axillary line\n- Kelly clamp used to bluntly dissect the underlying subcutaneous tissue muscle until left lung pleura reached\n- Index finger inserted into incision and used to sweep inside left chest cavity\n- chests tube size 22fr inserted with index finger guidance and chest tube connected to functioning underwater seal\n- incision site cleaned and chest tube secured with Prolene 1 purse-string suture.</div>"
},
{
"authorReference" : {
"reference" : "PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f"
},
"time" : "2022-06-28T18:10:00.000+08:00",
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">Keep left chest tube in secured\nmonitor VS every 30m, keep BP > 120/90\nContinue NP 3L/min\nProvide adequate analgesia\nSend for repeat chest PA once patient more conscious\nTrace CT brain preliminary report\nUpdate surgical team on finding, push for admission once patient return from X-ray</div>"
}
],
"usedCode" : [
{
"text" : "Silk suture"
},
{
"text" : "Forceps"
},
{
"text" : "Cannula, tube AND/OR catheter"
}
]
}