q-gl-initial
type: Questionnaire
node role: treeRoot
id:
  v: q-gl-initial
text:
  status:
    v: extensions
  div: Generated Narrative: Questionnaire q-gl-initial Structure LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> 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; …
url:
  v: http://fhir.hie.moh.gov.my/Questionnaire/q-gl-initial
version:
  v: 2.0.1
name:
  v: QGlInitial
title:
  v: Questionnaire Initial Guarantee Letter
status:
  v: active
date:
  v: 2024-03-13T01:41:41.3395961+00:00
publisher:
  v: MHNexus Sdn Bhd
contact:
  name:
    v: MHNexus Sdn Bhd
  telecom:
    system:
      v: url
    value:
      v: http://www.hl7.org/Special/committees/ | https://www.mhn.asia/
  telecom:
    system:
      v: email
description:
  v: Questionnaire for requesting a Guarantee Letter.
item:
  link id:
    v: HEADER
  text:
    v: Header
  type:
    v: group
  item:
    link id:
      v: GE HOSP_CODE
    text:
      v: GE PROVIDER CODE
    type:
      v: string
  item:
    link id:
      v: REQ_TYPE
    text:
      v: Request type
    type:
      v: choice
    answer option:
      value: Coding
    answer option:
      value: Coding
  item:
    link id:
      v: REQ_DATE
    text:
      v: Current date & time stamp
    type:
      v: dateTime
  item:
    link id:
      v: HOSP_CASENO
    text:
      v: Hospital admission case no
    type:
      v: string
item:
  link id:
    v: D1
  text:
    v: Details
  type:
    v: group
  item:
    link id:
      v: REC-ID
    text:
      v: REC-ID
    type:
      v: string
    max length:
      v: 20
  item:
    link id:
      v: PATIENT
    text:
      v: Patient Name
    type:
      v: string
    max length:
      v: 200
  item:
    link id:
      v: NEWIC
    text:
      v: IC (new)
    type:
      v: string
    max length:
      v: 14
  item:
    link id:
      v: IDNUM
    text:
      v: IC (old / others)
    type:
      v: string
    max length:
      v: 24
  item:
    link id:
      v: CLTSEX
    text:
      v: Sex
    type:
      v: choice
    answer option:
      value: Coding
    answer option:
      value: Coding
  item:
    link id:
      v: CLTAGE
    text:
      v: Age of Patient
    type:
      v: string
    max length:
      v: 3
  item:
    link id:
      v: POLICY_NO
    text:
      v: Policy No
    type:
      v: string
    max length:
      v: 10
  item:
    link id:
      v: HOSP_CONTACT
    text:
      v: Hospital contact number
    type:
      v: string
    max length:
      v: 20
  item:
    link id:
      v: HOSP_FAX
    text:
      v: Hospital Fax number
    type:
      v: string
    max length:
      v: 20
  item:
    link id:
      v: ADMISSION_DATE
    text:
      v: Admission /Planned Admission Date & Time
    type:
      v: dateTime
  item:
    link id:
      v: EXP_LOS
    text:
      v: Expected days of stay / Discharge date
    type:
      v: string
    max length:
      v: 10
  item:
    link id:
      v: SYMPTOMS
    text:
      v: Symtoms /Conditions requiring admission
    type:
      v: text
    max length:
      v: 500
  item:
    link id:
      v: BP_PULSE
    text:
      v: Patient's BP/Temp/Pulse
    type:
      v: text
    max length:
      v: 200
  item:
    link id:
      v: CLT_AWARE
    text:
      v: How long is patient aware of the condition

v: PA

v: Pre-Authorization Form /Initial GL request

v: EA

v: Elective Admission

v: male

v: Male

v: female

v: Female

v: dateTime

link id:
  v: SYMPTOMS_DATE
text:
  v: Date symptoms first appeared
type:
  v: dateTime

link id:
  v: DATE_CONSULTED
text:
  v: Date first consulted
type:
  v: dateTime

link id:
  v: PREV_CONSULT
text:
  v: Any previous consultation/treatment/hospitalization for this symptoms/illness or related conditions whether in this hospital or any other facilities
type:
  v: boolean

link id:
  v: REFERRED
text:
  v: Was the patient referred?
type:
  v: boolean
enable when:
  question:
    v: PREV_CONSULT
  operator:
    v: =
  answer: boolean
    v: true

link id:
  v: MEDICAL_HIST
text:
  v: Referred hospital & details
type:
  v: text
enable when:
  question:
    v: REFERRED
  operator:
    v: =
  answer: boolean
    v: true
max length:
  v: 200

link id:
  v: OUTPATIENT
text:
  v: The condition can be managed under outpatient basis
type:
  v: boolean

link id:
  v: REASON_NO_OP
text:
  v: Reason of admission
type:
  v: text
enable when:
  question:
    v: OUTPATIENT
  operator:
    v: =
  answer: boolean
    v: false
max length:
  v: 200

link id:
  v: ICD_CODE
text:
  v: Diagnosis Description
type:
  v: string
max length:
  v: 100

link id:
  v: 2nd_ICD
text:
  v: Secondary Diagnosis code
type:
  v: string
max length:
  v: 100

link id:
  v: ICD_DESC
text:
  v: Expected days of stay / Discharge date
type:
  v: text
max length:
  v: 500

link id:
  v: DIAGNOSIS_DATE
text:
  v: Diagnosis confirmed on date
type:
  v: dateTime

link id:
  v: ADVISED_DATE
text:
  v: Date when doctor first advised the diagnosis to patient
type:
  v: dateTime

link id:
  v: RELAPSE
text:
  v: Any possibility of relapse
type:
  v: boolean

link id:
  v: EST_COST
text:
  v: Estimated Cost
type:
  v: decimal

link id:
  v: ADMISSION_TYPE
text:
  v: Type of admission
type:
  v: choice
answer option:
  value: Coding
    code:
      v: IP
    display:
      v: Hospitalisation
answer option:
  value: Coding
    code:
      v: DC
    display:
      v: Day Care
answer option:
  value: Coding
    code:
      v: PR
    display:
      v: On patient's request

link id:
  v: ILLNESS_CONDITION
text:
  v: selected illness/condition related to the diagnosis
type:
  v: choice
answer option:
  value: Coding
    code:
      v: a
    display:
      v: Pregnancy / Childbirth / Infertility / Caesarean section/ miscarriage Or any complications arising therefrom
answer option:
  value: Coding
    code:
      v: b
    display:
      v: Congenital / Hereditary diseases
answer option:
  value: Coding
    code:
      v: c
    display:
      v: Influence of Drugs / Alcohol
answer option:
  value: Coding
    code:
      v: d
    display:
      v: Nervous / Mental / Emotional / Sleeping Disorder
answer option:
  value: Coding
    code:
      v: e
    display:
      v: Cosmetic reason / Dental care / refractive errors correction
answer option:
  value: Coding
    code:
      v: f
    display:
      v: AIDS / STD / VD / HIV
answer option:
  value: Coding
    code:
      v: g
    display:
      v: Self-inflicted injuries / Violation of laws / Strike / Riots
answer option:
  value: Coding
    code:
      v: h
    display:
      v: None of the above

link id:
  v: TREATMENT_PLAN
text:
  v: Medical treatment, Investigation and Surgical procedure to be performed
type:
  v: text
max length:
  v: 500

link id:
  v: DIABETES_MELLITUS
text:
  v: Does the patient have any Diabetes Mellitus condition?
type:
  v: boolean

link id:
  v: DIABETES_SINCE_WHEN
text:
  v: Date first diagnosed with Diabetes Mellitus
type:
  v: dateTime
enable when:
  question:
    v: DIABETES_MELLITUS
  operator:
    v: =
  answer: boolean
    v: true

link id:
  v: DIABETES_MED_DET
text:
  v: 1) doctor who first diagnosed (Name & Hosp) 2) usual treating doctor 3) current medications (name/dosage)
type:
  v: text
enable when:
  question:
    v: DIABETES_MELLITUS
  operator:
    v: =
  answer: boolean
    v: true
max length:
  v: 500

link id:
  v: HYPERTENSION
text:
  v: Does the patient have any hypertension condition?
type:
  v: boolean

link id:
  v: HYPERTENSION_SINCE_WHEN
text:
  v: Date first diagnosed with hypertension
type:
  v: dateTime
enable when:
  question:
    v: HYPERTENSION
  operator:
    v: =
  answer: boolean
    v: true

link id:
  v: HYPERTENSION_MED_DET
text:
  v: 1) doctor who first diagnosed (Name & Hosp) 2) usual treating doctor 3) current medications (name/dosage)
type:
  v: text
enable when:
  question:
    v: HYPERTENSION
  operator:
    v: =
  answer: boolean
    v: true
max length:
  v: 500

link id:
  v: HEART_DISEASE
text:
  v: Does the patient have any heart disease condition?
type:
  v: boolean

link id:
  v: HEART_DISEASE_SINCE_WHEN
text:
  v: Date first diagnosed with heart disease
type:
  v: dateTime
enable when:
  question:
    v: HEART_DISEASE
  operator:
    v: =
  answer: boolean
    v: true

link id:
  v: HEART_DIASEASE_MED_DET
text:
  v: 1) doctor who first diagnosed (Name & Hosp) 2) usual treating doctor 3) current medications (name/dosage)
type:
  v: string
enable when:
  question:
    v: HEART_DISEASE
  operator:
    v: =
  answer: boolean
    v: true
max length:
  v: 500

link id:
  v: OTH_MEDICAL
text:
  v: Other than above 3 specific illness. Does the patient have any other medical condition
type:
  v: boolean

link id:
  v: OTH_MEDICAL_DET
text:
  v: Other than above 3 specific illness. Doctor to provide other medical conditions if exist, if possible to provide medical conditions since date
type:
  v: text
enable when:
  question:
    v: OTH_MEDICAL
  operator:
    v: =
  answer: boolean
    v: true

link id:
  v: PREGNANT
text:
  v: Was the patient pregnant at the time of hospitalization
type:
  v: boolean

link id:
  v: ACCIDENTAL
text:
  v: Accidental case
type:
  v: boolean

link id:
  v: ACCIDENT_DATE
text:
  v: Date & time of Accident
type:
  v: dateTime
enable when:
  question:
    v: ACCIDENTAL
  operator:
    v: =
  answer: boolean
    v: true

link id:
  v: ACCIDENT_DET
text:
  v: Details of Accident
type:
  v: text
enable when:
  question:
    v: ACCIDENTAL
  operator:
    v: =
  answer: boolean
    v: true

link id:
  v: SURGICAL
text:
  v: Surgery is required
type:
  v: boolean

link id:
  v: SURGICAL_DATE
text:
  v: Date of Surgical
type:
  v: dateTime
enable when:
  question:
    v: SURGICAL
  operator:
    v: =
  answer: boolean
    v: true

link id:
  v: INJURY_DESC
text:
  v: Injury description
type:
  v: text

link id:
  v: HOSP_DOCTOR_CODE
text:
  v: Hospital doctor User Code
type:
  v: string

link id:
  v: PHYSICIAN
text:
  v: Name of Admitting / Treating doctor
type:
  v: string

link id:
  v: PHYSICIAN_SPECIALTY
text:
  v: Physician Specialty
type:
  v: string

link id:
  v: GL Number
text:
  v: GE Guarantee Letter Number
type:
  v: string

link id:
  v: Patient_Consent
text:
  v: Checklist - Patient's Consent and witness signature obtained
type:
  v: boolean