HL7® FHIR® Malaysia Core (MY Core) Implementation Guide
2.0.1 - ci-build

HL7® FHIR® Malaysia Core (MY Core) Implementation Guide - Local Development build (v2.0.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Questionnaire: Questionnaire Hypertension Clerking Note

Official URL: http://fhir.hie.moh.gov.my/Questionnaire/q-hpt-note Version: 2.0.1
Active as of 2024-02-12 Computable Name: QHptNote

Hypertension Clerking Note

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. QHptNoteHypertension Clerking NoteQuestionnairehttp://fhir.hie.moh.gov.my/Questionnaire/q-hpt-note#2.0.1
... hpt-note.1Concomitant Disease0..1group
.... hpt-note.1.1Diabetes Mellitus0..1boolean
.... hpt-note.1.2Renal Disease0..1boolean
.... hpt-note.1.3Heart Failure0..1boolean
.... hpt-note.1.4Gout0..1boolean
.... hpt-note.1.5Concomitant Disease Remarks0..1text
... hpt-note.2Past Medical Admissions for Hypertension0..1group
.... hpt-note.2.1Any Ward Admissions For Hypertension Emergencies0..1boolean
.... hpt-note.2.2Any Emergency Department Encounters0..1boolean
.... hpt-note.2.3Past Medical Admissions Remarks0..1text
... hpt-note.3Medication Summary0..1group
.... hpt-note.3.1Findings0..1text
... hpt-note.4Smoking History0..1group
.... hpt-note.4.1Starting Date of Smoking0..1date
.... hpt-note.4.2How Many Cigarettes Per Day0..1integer
.... hpt-note.4.3Pack Years of Smoking (years)0..1integer
... hpt-note.5Social History0..1group
.... hpt-note.5.1Findings0..1text
... hpt-note.6Family History0..1group
.... hpt-note.6.1Findings0..1text
... hpt-note.7Symptoms0..1group
.... hpt-note.7.1Visual Disturbances0..1boolean
.... hpt-note.7.2Chest Pain0..1boolean
.... hpt-note.7.3Lower Limb Swellings0..1boolean
.... hpt-note.7.4Headache0..1boolean
.... hpt-note.7.5Vomiting0..1boolean
.... hpt-note.7.6Limb Weakness0..1boolean
.... hpt-note.7.7Shortness of Breath0..1boolean
.... hpt-note.7.8Symptoms Remarks0..1text
... hpt-note.8History of Presenting Illness Summary0..1group
.... hpt-note.8.1Findings0..1text
... hpt-note.9Initial Vital Signs0..1group
.... hpt-note.9.1Systolic Blood Pressure (mmHg)0..1quantityInitial Value: Quantity = ? mmHg
.... hpt-note.9.2Diastolic Blood Pressure (mmHg)0..1quantityEnable When: hpt-note.9.1 exists
Initial Value: Quantity = ? mmHg
.... hpt-note.9.9Heart Rate (/min)0..1quantityInitial Value: Quantity = ? per minute
.... hpt-note.9.10Oxygen Saturation (%)0..1quantityInitial Value: Quantity = ? %
.... hpt-note.9.11Body Temperature (°C)0..1quantityInitial Value: Quantity = ? °C
.... hpt-note.9.12Pain score0..1quantity
.... hpt-note.9.13Respiratory Rate (/min)0..1quantityInitial Value: Quantity = ? per minute
... hpt-note.10Blood Pressure Second Reading0..1group
.... hpt-note.10.1Systolic Blood Pressure Second Reading (mmHg)0..1quantityInitial Value: Quantity = ? mmHg
.... hpt-note.10.2Diastolic Blood Pressure Second Reading (mmHg)0..1quantityEnable When: hpt-note.10.1 exists
Initial Value: Quantity = ? mmHg
.... hpt-note.10.3Recorded Time0..1dateTime
... hpt-note.11Blood Pressure Standing0..1group
.... hpt-note.11.1Systolic Blood Pressure Standing (mmHg)0..1quantityInitial Value: Quantity = ? mmHg
.... hpt-note.11.2Diastolic Blood Pressure Standing (mmHg)0..1quantityEnable When: hpt-note.11.1 exists
Initial Value: Quantity = ? mmHg
.... hpt-note.11.3Recorded Time0..1dateTime
... hpt-note.12Blood Pressure Seated0..1group
.... hpt-note.12.1Systolic Blood Pressure Seated (mmHg)0..1quantityInitial Value: Quantity = ? mmHg
.... hpt-note.12.2Diastolic Blood Pressure Seated (mmHg)0..1quantityEnable When: hpt-note.12.1 exists
Initial Value: Quantity = ? mmHg
.... hpt-note.12.3Recorded Time0..1dateTime
... hpt-note.13Central Nervous System Examinations0..1group
.... hpt-note.13.1Findings0..1text
... hpt-note.14Eye Examination0..1group
.... hpt-note.14.1Findings0..1text
... hpt-note.15Cranial Nerves Examination0..1group
.... hpt-note.15.1Findings0..1text
... hpt-note.16Cardiac Examination0..1group
.... hpt-note.16.1Findings0..1text
... hpt-note.17General Endocrine Examination0..1group
.... hpt-note.17.1Findings0..1text
... hpt-note.18Abdominal Examination0..1group
.... hpt-note.18.1Findings0..1text
... hpt-note.19Respiratory Examination0..1group
.... hpt-note.19.1Findings0..1text
... hpt-note.20General Examination Findings Summary0..1group
.... hpt-note.20.1Findings0..1text
... hpt-note.21Investigations / Special Test0..1group
.... hpt-note.21.1Fundoscopy0..1text
.... hpt-note.21.2US KUB Findings0..1text
.... hpt-note.21.3CT Scan Findings0..1text
.... hpt-note.21.4Xray Findings0..1text
.... hpt-note.21.5General Investigations / Summary0..1text
... hpt-note.22Diagnosis0..1group
.... hpt-note.22.1Diagnosis0..1text
... hpt-note.23Management / Treatment0..1group
.... hpt-note.23.1Management Summary0..1text
... hpt-note.24TCA Date0..1group
.... hpt-note.24.1Date0..1dateTime
... hpt-note.25Referral0..1group
.... hpt-note.25.1Reason for Referral0..1text
.... hpt-note.25.2Spoken To0..1string
.... hpt-note.25.3Time of Referral made0..1dateTime

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