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
<Procedure xmlns="http://hl7.org/fhir">
<id value="example-procedure"/>
<meta>
<versionId value="2"/>
<lastUpdated value="2022-09-07T09:04:34.378+08:00"/>
<source value="http://provider.hie.moh.gov.my"/>
<profile
value="http://fhir.hie.moh.gov.my/StructureDefinition/Procedure-my-core"/>
</meta>
<text>
<status value="generated"/>
<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.
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> (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
monitor VS every 30m, keep BP &gt; 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> (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>
</text>
<status value="completed"/>
<category>
<coding>
<system value="http://snomed.info/sct"/>
<code value="387713003"/>
<display value="Surgical procedure"/>
</coding>
</category>
<code>
<coding>
<system
value="http://fhir.hie.moh.gov.my/CodeSystem/procedure-code-my-core"/>
<code value="34"/>
<display
value="Operations on chest wall, pleura, mediastinum, and diaphragm"/>
</coding>
</code>
<subject>
<reference value="Patient/f92c383f-68de-46c1-8cde-970efa2d0f15"/>
</subject>
<encounter>
<reference value="Encounter/5579c35d-97af-463a-b4d7-df2d9e3dc267"/>
</encounter>
<performedPeriod>
<start value="2022-06-28T15:30:00.000+08:00"/>
<end value="2022-06-28T18:00:00.000+08:00"/>
</performedPeriod>
<recorder>
<reference value="PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba"/>
</recorder>
<asserter>
<reference value="PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f"/>
</asserter>
<performer>
<function>
<coding>
<system value="http://snomed.info/sct"/>
<code value="309294001"/>
<display value="Accident and emergency doctor"/>
</coding>
</function>
<actor>
<reference
value="PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f"/>
</actor>
<onBehalfOf>
<reference value="Organization/11-05040012"/>
</onBehalfOf>
</performer>
<performer>
<function>
<coding>
<system value="http://snomed.info/sct"/>
<code value="158972004"/>
<display value="House officer"/>
</coding>
</function>
<actor>
<reference
value="PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba"/>
</actor>
<onBehalfOf>
<reference value="Organization/11-05060009"/>
</onBehalfOf>
</performer>
<location>
<reference value="Location/8d988a14-4e08-4b57-a6d2-323218dcb76e"/>
</location>
<bodySite>
<text value="Left thorax structure"/>
</bodySite>
<outcome>
<coding>
<system value="http://snomed.info/sct"/>
<code value="385669000"/>
<display value="Successful"/>
</coding>
</outcome>
<complication>
<text value="Complication 1"/>
</complication>
<complication>
<text value="Complication 2"/>
</complication>
<note>
<authorReference>
<reference
value="PractitionerRole/cd16e0cb-3e0f-43bb-9197-901f5daff3ba"/>
</authorReference>
<time value="2022-06-28T18:00:00.000+08:00"/>
<text
value="<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>"/>
</note>
<note>
<authorReference>
<reference
value="PractitionerRole/6f1d7a69-b46b-4464-ade6-08a967eb518f"/>
</authorReference>
<time value="2022-06-28T18:10:00.000+08:00"/>
<text
value="<div xmlns="http://www.w3.org/1999/xhtml">Keep left chest tube in secured
monitor VS every 30m, keep BP &gt; 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>"/>
</note>
<usedCode>
<text value="Silk suture"/>
</usedCode>
<usedCode>
<text value="Forceps"/>
</usedCode>
<usedCode>
<text value="Cannula, tube AND/OR catheter"/>
</usedCode>
</Procedure>