Generated Narrative: Questionnaire q-gl-initial Structure LinkID Text Cardinality Type Description & Constraints QGlInitial Questionnaire for requesting a Guarantee Letter. Questionnaire http://fhir.hie.moh.gov.my/Questionnaire/q-gl-initial#2.0.1 #xD; HEADER Header 0..1 group #xD; GE HOSP_CODE GE PROVIDER CODE 0..1 string #xD; REQ_TYPE Request type 0..1 choice Options: 2 options #xD; REQ_DATE Current date & time stamp 0..1 dateTime #xD; HOSP_CASENO Hospital admission case no 0..1 string #xD; D1 Details 0..1 group #xD; REC-ID REC-ID 0..1 string Max Length: 20 #xD; PATIENT Patient Name 0..1 string Max Length: 200 #xD; NEWIC IC (new) 0..1 string Max Length: 14 #xD; IDNUM IC (old / others) 0..1 string Max Length: 24 #xD; CLTSEX Sex 0..1 choice Options: 2 options #xD; CLTAGE Age of Patient 0..1 string Max Length: 3 #xD; POLICY_NO Policy No 0..1 string Max Length: 10 #xD; HOSP_CONTACT Hospital contact number 0..1 string Max Length: 20 #xD; HOSP_FAX Hospital Fax number 0..1 string Max Length: 20 #xD; ADMISSION_DATE Admission /Planned Admission Date & Time 0..1 dateTime #xD; EXP_LOS Expected days of stay / Discharge date 0..1 string Max Length: 10 #xD; SYMPTOMS Symtoms /Conditions requiring admission 0..1 text Max Length: 500 #xD; BP_PULSE Patient's BP/Temp/Pulse 0..1 text Max Length: 200 #xD; CLT_AWARE How long is patient aware of the condition 0..1 dateTime #xD; SYMPTOMS_DATE Date symptoms first appeared 0..1 dateTime #xD; DATE_CONSULTED Date first consulted 0..1 dateTime #xD; PREV_CONSULT Any previous consultation/treatment/hospitalization for this symptoms/illness or related conditions whether in this hospital or any other facilities 0..1 boolean #xD; REFERRED Was the patient referred? 0..1 boolean Enable When: PREV_CONSULT = #xD; MEDICAL_HIST Referred hospital & details 0..1 text Max Length: 200 Enable When: REFERRED = #xD; OUTPATIENT The condition can be managed under outpatient basis 0..1 boolean #xD; REASON_NO_OP Reason of admission 0..1 text Max Length: 200 Enable When: OUTPATIENT = #xD; ICD_CODE Diagnosis Description 0..1 string Max Length: 100 #xD; 2nd_ICD Secondary Diagnosis code 0..1 string Max Length: 100 #xD; ICD_DESC Expected days of stay / Discharge date 0..1 text Max Length: 500 #xD; DIAGNOSIS_DATE Diagnosis confirmed on date 0..1 dateTime #xD; ADVISED_DATE Date when doctor first advised the diagnosis to patient 0..1 dateTime #xD; RELAPSE Any possibility of relapse 0..1 boolean #xD; EST_COST Estimated Cost 0..1 decimal #xD; ADMISSION_TYPE Type of admission 0..1 choice Options: 3 options #xD; ILLNESS_CONDITION selected illness/condition related to the diagnosis 0..1 choice Options: 8 options #xD; TREATMENT_PLAN Medical treatment, Investigation and Surgical procedure to be performed 0..1 text Max Length: 500 #xD; DIABETES_MELLITUS Does the patient have any Diabetes Mellitus condition? 0..1 boolean #xD; DIABETES_SINCE_WHEN Date first diagnosed with Diabetes Mellitus 0..1 dateTime Enable When: DIABETES_MELLITUS = #xD; DIABETES_MED_DET 1) doctor who first diagnosed (Name & Hosp) 2) usual treating doctor 3) current medications (name/dosage) 0..1 text Max Length: 500 Enable When: DIABETES_MELLITUS = #xD; HYPERTENSION Does the patient have any hypertension condition? 0..1 boolean #xD; HYPERTENSION_SINCE_WHEN Date first diagnosed with hypertension 0..1 dateTime Enable When: HYPERTENSION = #xD; HYPERTENSION_MED_DET 1) doctor who first diagnosed (Name & Hosp) 2) usual treating doctor 3) current medications (name/dosage) 0..1 text Max Length: 500 Enable When: HYPERTENSION = #xD; HEART_DISEASE Does the patient have any heart disease condition? 0..1 boolean #xD; HEART_DISEASE_SINCE_WHEN Date first diagnosed with heart disease 0..1 dateTime Enable When: HEART_DISEASE = #xD; HEART_DIASEASE_MED_DET 1) doctor who first diagnosed (Name & Hosp) 2) usual treating doctor 3) current medications (name/dosage) 0..1 string Max Length: 500 Enable When: HEART_DISEASE = #xD; OTH_MEDICAL Other than above 3 specific illness. Does the patient have any other medical condition 0..1 boolean #xD; OTH_MEDICAL_DET Other than above 3 specific illness. Doctor to provide other medical conditions if exist, if possible to provide medical conditions since date 0..1 text Enable When: OTH_MEDICAL = #xD; PREGNANT Was the patient pregnant at the time of hospitalization 0..1 boolean #xD; ACCIDENTAL Accidental case 0..1 boolean #xD; ACCIDENT_DATE Date & time of Accident 0..1 dateTime Enable When: ACCIDENTAL = #xD; ACCIDENT_DET Details of Accident 0..1 text Enable When: ACCIDENTAL = #xD; SURGICAL Surgery is required 0..1 boolean #xD; SURGICAL_DATE Date of Surgical 0..1 dateTime Enable When: SURGICAL = #xD; INJURY_DESC Injury description 0..1 text #xD; HOSP_DOCTOR_CODE Hospital doctor User Code 0..1 string #xD; PHYSICIAN Name of Admitting / Treating doctor 0..1 string #xD; PHYSICIAN_SPECIALTY Physician Specialty 0..1 string #xD; GL Number GE Guarantee Letter Number 0..1 string #xD; Patient_Consent Checklist - Patient's Consent and witness signature obtained 0..1 boolean #xD; Documentation for this format Options Sets Answer options for REQ_TYPE null#PA ("Pre-Authorization Form /Initial GL request") null#EA ("Elective Admission") Answer options for CLTSEX http://hl7.org/fhir/administrative-gender#male ("Male") http://hl7.org/fhir/administrative-gender#female ("Female") Answer options for ADMISSION_TYPE null#IP ("Hospitalisation") null#DC ("Day Care") null#PR ("On patient's request") Answer options for ILLNESS_CONDITION null#a ("Pregnancy / Childbirth / Infertility / Caesarean section/ miscarriage Or any complications arising therefrom") null#b ("Congenital / Hereditary diseases") null#c ("Influence of Drugs / Alcohol") null#d ("Nervous / Mental / Emotional / Sleeping Disorder") null#e ("Cosmetic reason / Dental care / refractive errors correction") null#f ("AIDS / STD / VD / HIV") null#g ("Self-inflicted injuries / Violation of laws / Strike / Riots") null#h ("None of the above")
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Questionnaire for requesting a Guarantee Letter.
Pre-Authorization Form /Initial GL request
Admission /Planned Admission Date & Time
How long is patient aware of the condition
Any previous consultation/treatment/hospitalization for this symptoms/illness or related conditions whether in this hospital or any other facilities
The condition can be managed under outpatient basis
Date when doctor first advised the diagnosis to patient
selected illness/condition related to the diagnosis
Pregnancy / Childbirth / Infertility / Caesarean section/ miscarriage Or any complications arising therefrom
Nervous / Mental / Emotional / Sleeping Disorder
Cosmetic reason / Dental care / refractive errors correction
Self-inflicted injuries / Violation of laws / Strike / Riots
Medical treatment, Investigation and Surgical procedure to be performed
Does the patient have any Diabetes Mellitus condition?
Date first diagnosed with Diabetes Mellitus
1) doctor who first diagnosed (Name & Hosp) 2) usual treating doctor 3) current medications (name/dosage)
Does the patient have any hypertension condition?
Does the patient have any heart disease condition?
Other than above 3 specific illness. Does the patient have any other medical condition
Other than above 3 specific illness. Doctor to provide other medical conditions if exist, if possible to provide medical conditions since date
Was the patient pregnant at the time of hospitalization
Checklist - Patient's Consent and witness signature obtained