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
@prefix fhir: <http://hl7.org/fhir/> .
@prefix owl: <http://www.w3.org/2002/07/owl#> .
@prefix rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#> .
@prefix rdfs: <http://www.w3.org/2000/01/rdf-schema#> .
@prefix sct: <http://snomed.info/id/> .
@prefix xsd: <http://www.w3.org/2001/XMLSchema#> .
# - resource -------------------------------------------------------------------
a fhir:Procedure ;
fhir:nodeRole fhir:treeRoot ;
fhir:id [ fhir:v "example-procedure"] ; #
fhir:meta [
fhir:versionId [ fhir:v "2" ] ;
fhir:lastUpdated [ fhir:v "2022-09-07T09:04:34.378+08:00"^^xsd:dateTime ] ;
fhir:source [ fhir:v "http://provider.hie.moh.gov.my"^^xsd:anyURI ] ;
( fhir:profile [
fhir:v "http://fhir.hie.moh.gov.my/StructureDefinition/Procedure-my-core"^^xsd:anyURI ;
fhir:link <http://fhir.hie.moh.gov.my/StructureDefinition/Procedure-my-core> ] )
] ; #
fhir:text [
fhir:status [ fhir:v "generated" ] ;
fhir: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>"^^rdf:XMLLiteral
] ; #
fhir:status [ fhir:v "completed"] ; #
fhir:category [
( fhir:coding [
a sct:387713003 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "387713003" ] ;
fhir:display [ fhir:v "Surgical procedure" ] ] )
] ; #
fhir:code [
( fhir:coding [
fhir:system [ fhir:v "http://fhir.hie.moh.gov.my/CodeSystem/procedure-code-my-core"^^xsd:anyURI ] ;
fhir:code [ fhir:v "34" ] ;
fhir:display [ fhir:v "Operations on chest wall, pleura, mediastinum, and diaphragm" ] ] )
] ; #
fhir:subject [
fhir:reference [ fhir:v "Patient/f92c383f-68de-46c1-8cde-970efa2d0f15" ]
] ; #
fhir:encounter [
fhir:reference [ fhir:v "Encounter/5579c35d-97af-463a-b4d7-df2d9e3dc267" ]
] ; #
fhir:performed [
a fhir:Period ;
fhir:start [ fhir:v "2022-06-28T15:30:00.000+08:00"^^xsd:dateTime ] ;
fhir:end [ fhir:v "2022-06-28T18:00:00.000+08:00"^^xsd:dateTime ]
] ; #
fhir:recorder [
fhir:reference [ fhir:v "PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba" ]
] ; #
fhir:asserter [
fhir:reference [ fhir:v "PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f" ]
] ; #
fhir:performer ( [
fhir:function [
( fhir:coding [
a sct:309294001 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "309294001" ] ;
fhir:display [ fhir:v "Accident and emergency doctor" ] ] ) ] ;
fhir:actor [
fhir:reference [ fhir:v "PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f" ] ] ;
fhir:onBehalfOf [
fhir:reference [ fhir:v "Organization/11-05040012" ] ]
] [
fhir:function [
( fhir:coding [
a sct:158972004 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "158972004" ] ;
fhir:display [ fhir:v "House officer" ] ] ) ] ;
fhir:actor [
fhir:reference [ fhir:v "PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba" ] ] ;
fhir:onBehalfOf [
fhir:reference [ fhir:v "Organization/11-05060009" ] ]
] ) ; #
fhir:location [
fhir:reference [ fhir:v "Location/8d988a14-4e08-4b57-a6d2-323218dcb76e" ]
] ; #
fhir:bodySite ( [
fhir:text [ fhir:v "Left thorax structure" ]
] ) ; #
fhir:outcome [
( fhir:coding [
a sct:385669000 ;
fhir:system [ fhir:v "http://snomed.info/sct"^^xsd:anyURI ] ;
fhir:code [ fhir:v "385669000" ] ;
fhir:display [ fhir:v "Successful" ] ] )
] ; #
fhir:complication ( [
fhir:text [ fhir:v "Complication 1" ]
] [
fhir:text [ fhir:v "Complication 2" ]
] ) ; #
fhir:note ( [
fhir:author [
a fhir:Reference ;
fhir:reference [ fhir:v "PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba" ] ] ;
fhir:time [ fhir:v "2022-06-28T18:00:00.000+08:00"^^xsd:dateTime ] ;
fhir:text [ fhir:v "<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>" ]
] [
fhir:author [
a fhir:Reference ;
fhir:reference [ fhir:v "PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f" ] ] ;
fhir:time [ fhir:v "2022-06-28T18:10:00.000+08:00"^^xsd:dateTime ] ;
fhir:text [ fhir:v "<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>" ]
] ) ; #
fhir:usedCode ( [
fhir:text [ fhir:v "Silk suture" ]
] [
fhir:text [ fhir:v "Forceps" ]
] [
fhir:text [ fhir:v "Cannula, tube AND/OR catheter" ]
] ) . #
IG © 2022+ MHNexus Sdn Bhd. Package MyCore#2.0.0 based on FHIR 4.0.1. Generated 2025-03-27
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