q-hpt-note
type: Questionnaire
node role: treeRoot
id:
  v: q-hpt-note
text:
  status:
    v: extensions
  div: Generated Narrative: Questionnaire q-hpt-note LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> QHptNote Hypertension Clerking Note Questionnaire http://fhir.hie.moh.gov.my/Questionnaire/q-hpt-note#2.0.1 #xD; hpt-note.1 Concomitant Disease 0..1 group #xD; hpt-note.1.1 Diabetes Mellitus 0..1 boolean #xD; hpt-note.1.2 Renal Disease 0..1 boolean #xD; hpt-note.1.3 Heart Failure 0..1 boolean #xD; hpt-note.1.4 Gout 0..1 boolean #xD; hpt-note.1.5 Concomitant Disease Remarks 0..1 text #xD; hpt-note.2 Past Medical Admissions for Hypertension 0..1 group #xD; hpt-note.2.1 Any Ward Admissions For Hypertension Emergencies 0..1 boolean #xD; hpt-note.2.2 Any Emergency Department Encounters 0..1 boolean #xD; hpt-note.2.3 Past Medical Admissions Remarks 0..1 text #xD; hpt-note.3 Medication Summary 0..1 group #xD; hpt-note.3.1 Findings 0..1 text #xD; hpt-note.4 Smoking History 0..1 group #xD; hpt-note.4.1 Starting Date of Smoking 0..1 date #xD; hpt-note.4.2 How Many Cigarettes Per Day 0..1 integer #xD; hpt-note.4.3 Pack Years of Smoking (years) 0..1 integer #xD; hpt-note.5 Social History 0..1 group #xD; hpt-note.5.1 Findings 0..1 text #xD; hpt-note.6 Family History 0..1 group #xD; hpt-note.6.1 Findings 0..1 text #xD; hpt-note.7 Symptoms 0..1 group #xD; hpt-note.7.1 Visual Disturbances 0..1 boolean #xD; hpt-note.7.2 Chest Pain 0..1 boolean #xD; hpt-note.7.3 Lower Limb Swellings 0..1 boolean #xD; hpt-note.7.4 Headache 0..1 boolean #xD; hpt-note.7.5 Vomiting 0..1 boolean #xD; hpt-note.7.6 Limb Weakness 0..1 boolean #xD; hpt-note.7.7 Shortness of Breath 0..1 boolean #xD; hpt-note.7.8 Symptoms Remarks 0..1 text #xD; hpt-note.8 History of Presenting Illness Summary 0..1 group #xD; hpt-note.8.1 Findings 0..1 text #xD; hpt-note.9 Initial Vital Signs 0..1 group #xD; hpt-note.9.1 Systolic Blood Pressure (mmHg) 0..1 quantity Initial Value: Quantity = ? mmHg #xD; hpt-note.9.2 Diastolic Blood Pressure (mmHg) 0..1 quantity Enab…
url:
  v: http://fhir.hie.moh.gov.my/Questionnaire/q-hpt-note
version:
  v: 2.0.1
name:
  v: QHptNote
title:
  v: Questionnaire Hypertension Clerking Note
status:
  v: active
date:
  v: 2024-02-12T04:04:09.5621857+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: Hypertension Clerking Note
item:
  link id:
    v: hpt-note.1
  text:
    v: Concomitant Disease
  type:
    v: group
  item:
    link id:
      v: hpt-note.1.1
    text:
      v: Diabetes Mellitus
    type:
      v: boolean
  item:
    link id:
      v: hpt-note.1.2
    text:
      v: Renal Disease
    type:
      v: boolean
  item:
    link id:
      v: hpt-note.1.3
    text:
      v: Heart Failure
    type:
      v: boolean
  item:
    link id:
      v: hpt-note.1.4
    text:
      v: Gout
    type:
      v: boolean
  item:
    link id:
      v: hpt-note.1.5
    text:
      v: Concomitant Disease Remarks
    type:
      v: text
item:
  link id:
    v: hpt-note.2
  text:
    v: Past Medical Admissions for Hypertension
  type:
    v: group
  item:
    link id:
      v: hpt-note.2.1
    text:
      v: Any Ward Admissions For Hypertension Emergencies
    type:
      v: boolean
  item:
    link id:
      v: hpt-note.2.2
    text:
      v: Any Emergency Department Encounters
    type:
      v: boolean
  item:
    link id:
      v: hpt-note.2.3
    text:
      v: Past Medical Admissions Remarks
    type:
      v: text
item:
  link id:
    v: hpt-note.3
  text:
    v: Medication Summary
  type:
    v: group
  item:
    link id:
      v: hpt-note.3.1
    text:
      v: Findings
    type:
      v: text
item:
  link id:
    v: hpt-note.4
  text:
    v: Smoking History
  type:
    v: group
  item:
    link id:
      v: hpt-note.4.1
    text:
      v: Starting Date of Smoking
    type:
      v: date
  item:
    link id:
      v: hpt-note.4.2
    text:
      v: How Many Cigarettes Per Day
    type:
      v: integer
  item:
    link id:
      v: hpt-note.4.3
    text:
      v: Pack Years of Smoking (years)
    type:
      v: integer
item:
  link id:
    v: hpt-note.5
  text:
    v: Social History
  type:
    v: group
  item:
    link id:
      v: hpt-note.5.1
    text:
      v: Findings
    type:
      v: text
item:
  link id:
    v: hpt-note.6
  text:
    v: Family History
  type:
    v: group
  item:
    link id:
      v: hpt-note.6.1
    text:
      v: Findings
    type:
      v: text
item:
  link id:
    v: hpt-note.7
  text:
    v: Symptoms
  type:
    v: group
  item:
    link id:
      v: hpt-note.7.1
    text:
      v: Visual Disturbances
    type:
      v: boolean
  item:
    link id:
      v: hpt-note.7.2
    text:
      v: Chest Pain
    type:
      v: boolean
  item:
    link id:
      v: hpt-note.7.3
    text:
      v: Lower Limb Swellings
    type:
      v: boolean

link id:
  v: hpt-note.7.4
text:
  v: Headache
type:
  v: boolean

link id:
  v: hpt-note.7.5
text:
  v: Vomiting
type:
  v: boolean

link id:
  v: hpt-note.7.6
text:
  v: Limb Weakness
type:
  v: boolean

link id:
  v: hpt-note.7.7
text:
  v: Shortness of Breath
type:
  v: boolean

link id:
  v: hpt-note.7.8
text:
  v: Symptoms Remarks
type:
  v: text

link id:
  v: hpt-note.8
text:
  v: History of Presenting Illness Summary
type:
  v: group
item:
  link id:
    v: hpt-note.8.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: hpt-note.9
text:
  v: Initial Vital Signs
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 1
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 300
  link id:
    v: hpt-note.9.1
  code: https://loinc.org/rdf/8480-6
    system:
      v: http://loinc.org
    code:
      v: 8480-6
    display:
      v: Systolic Blood Pressure
  text:
    v: Systolic Blood Pressure (mmHg)
  type:
    v: quantity
  initial:
    value: Quantity
      unit:
        v: mmHg
      system:
        v: http://unitsofmeasure.org
      code:
        v: mm[Hg]
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 1
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 250
  link id:
    v: hpt-note.9.2
  code: https://loinc.org/rdf/8462-4
    system:
      v: http://loinc.org
    code:
      v: 8462-4
    display:
      v: Diastolic Blood Pressure
  text:
    v: Diastolic Blood Pressure (mmHg)
  type:
    v: quantity
  enable when:
    question:
      v: hpt-note.9.1
    operator:
      v: exists
    answer: boolean
      v: true
  initial:
    value: Quantity
      unit:
        v: mmHg
      system:
        v: http://unitsofmeasure.org
      code:
        v: mm[Hg]
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 0
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 400
  link id:
    v: hpt-note.9.9
  text:
    v: Heart Rate (/min)
  type:
    v: quantity
  initial:
    value: Quantity
      unit:
        v: per minute
      system:
        v: http://unitsofmeasure.org
      code:
        v: /min
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 0
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 100
  link id:
    v: hpt-note.9.10
  text:
    v: Oxygen Saturation (%)
  type:
    v: quantity
  initial:
    value: Quantity
      unit:
        v: %
      system:
        v: http://unitsofmeasure.org
      code:
        v: %
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 0
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 100
  link id:
    v: hpt-note.9.11
  code: https://loinc.org/rdf/8310-5
    system:
      v: http://loinc.org
    code:
      v: 8310-5
    display:
      v: Body Temperature
  text:
    v: Body Temperature (°C)
  type:
    v: quantity
  initial:
    value: Quantity
      unit:
        v: °C
      system:
        v: http://unitsofmeasure.org
      code:
        v: Cel
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 0
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 10
  link id:
    v: hpt-note.9.12
  text:
    v: Pain score
  type:
    v: quantity
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 0
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 80
  link id:
    v: hpt-note.9.13
  text:
    v: Respiratory Rate (/min)
  type:
    v: quantity
  initial:
    value: Quantity
      unit:
        v: per minute
      system:
        v: http://unitsofmeasure.org
      code:
        v: /min

link id:
  v: hpt-note.10
text:
  v: Blood Pressure Second Reading
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 1
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 300
  link id:
    v: hpt-note.10.1
  code: https://loinc.org/rdf/8480-6
    system:
      v: http://loinc.org
    code:
      v: 8480-6
    display:
      v: Systolic Blood Pressure
  text:
    v: Systolic Blood Pressure Second Reading (mmHg)
  type:
    v: quantity
  initial:
    value: Quantity
      unit:
        v: mmHg
      system:
        v: http://unitsofmeasure.org
      code:
        v: mm[Hg]
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 1
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 250
  link id:
    v: hpt-note.10.2
  code: https://loinc.org/rdf/8462-4
    system:
      v: http://loinc.org
    code:
      v: 8462-4
    display:
      v: Diastolic Blood Pressure
  text:
    v: Diastolic Blood Pressure Second Reading (mmHg)
  type:
    v: quantity
  enable when:
    question:
      v: hpt-note.10.1
    operator:
      v: exists
    answer: boolean
      v: true
  initial:
    value: Quantity
      unit:
        v: mmHg
      system:
        v: http://unitsofmeasure.org
      code:
        v: mm[Hg]
item:
  link id:
    v: hpt-note.10.3
  text:
    v: Recorded Time
  type:
    v: dateTime

link id:
  v: hpt-note.11
text:
  v: Blood Pressure Standing
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 1
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 300
  link id:
    v: hpt-note.11.1
  code: https://loinc.org/rdf/8480-6
    system:
      v: http://loinc.org
    code:
      v: 8480-6
    display:
      v: Systolic Blood Pressure
  text:
    v: Systolic Blood Pressure Standing (mmHg)
  type:
    v: quantity
  initial:
    value: Quantity
      unit:
        v: mmHg
      system:
        v: http://unitsofmeasure.org
      code:
        v: mm[Hg]
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 1
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 250
  link id:
    v: hpt-note.11.2
  code: https://loinc.org/rdf/8462-4
    system:
      v: http://loinc.org
    code:
      v: 8462-4
    display:
      v: Diastolic Blood Pressure
  text:
    v: Diastolic Blood Pressure Standing (mmHg)
  type:
    v: quantity
  enable when:
    question:
      v: hpt-note.11.1
    operator:
      v: exists
    answer: boolean
      v: true
  initial:
    value: Quantity
      unit:
        v: mmHg
      system:
        v: http://unitsofmeasure.org
      code:
        v: mm[Hg]
item:
  link id:
    v: hpt-note.11.3
  text:
    v: Recorded Time
  type:
    v: dateTime

link id:
  v: hpt-note.12
text:
  v: Blood Pressure Seated
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 1
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 300
  link id:
    v: hpt-note.12.1
  text:
    v: Systolic Blood Pressure Seated (mmHg)
  type:
    v: quantity
  initial:
    value: Quantity
      unit:
        v: mmHg
      system:
        v: http://unitsofmeasure.org
      code:
        v: mm[Hg]
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/minValue-my-core
    value: integer
      v: 1
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/maxValue-my-core
    value: integer
      v: 250
  link id:
    v: hpt-note.12.2
  code: https://loinc.org/rdf/8462-4
    system:
      v: http://loinc.org
    code:
      v: 8462-4
    display:
      v: Diastolic Blood Pressure
  text:
    v: Diastolic Blood Pressure Seated (mmHg)
  type:
    v: quantity
  enable when:
    question:
      v: hpt-note.12.1
    operator:
      v: exists
    answer: boolean
      v: true
  initial:
    value: Quantity
      unit:
        v: mmHg
      system:
        v: http://unitsofmeasure.org
      code:
        v: mm[Hg]
item:
  link id:
    v: hpt-note.12.3
  text:
    v: Recorded Time
  type:
    v: dateTime

link id:
  v: hpt-note.13
text:
  v: Central Nervous System Examinations
type:
  v: group
item:
  link id:
    v: hpt-note.13.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: hpt-note.14
text:
  v: Eye Examination
type:
  v: group
item:
  link id:
    v: hpt-note.14.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: hpt-note.15
text:
  v: Cranial Nerves Examination
type:
  v: group
item:
  link id:
    v: hpt-note.15.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: hpt-note.16
text:
  v: Cardiac Examination
type:
  v: group
item:
  link id:
    v: hpt-note.16.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: hpt-note.17
text:
  v: General Endocrine Examination
type:
  v: group
item:
  link id:
    v: hpt-note.17.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: hpt-note.18
text:
  v: Abdominal Examination
type:
  v: group
item:
  link id:
    v: hpt-note.18.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: hpt-note.19
text:
  v: Respiratory Examination
type:
  v: group
item:
  link id:
    v: hpt-note.19.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: hpt-note.20
text:
  v: General Examination Findings Summary
type:
  v: group
item:
  link id:
    v: hpt-note.20.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: hpt-note.21
text:
  v: Investigations / Special Test
type:
  v: group
item:
  link id:
    v: hpt-note.21.1
  text:
    v: Fundoscopy
  type:
    v: text
item:
  link id:
    v: hpt-note.21.2
  text:
    v: US KUB Findings
  type:
    v: text
item:
  link id:
    v: hpt-note.21.3
  text:
    v: CT Scan Findings
  type:
    v: text
item:
  link id:
    v: hpt-note.21.4
  text:
    v: Xray Findings
  type:
    v: text
item:
  link id:
    v: hpt-note.21.5
  text:
    v: General Investigations / Summary
  type:
    v: text

link id:
  v: hpt-note.22
text:
  v: Diagnosis
type:
  v: group
item:
  link id:
    v: hpt-note.22.1
  text:
    v: Diagnosis
  type:
    v: text

link id:
  v: hpt-note.23
text:
  v: Management / Treatment
type:
  v: group
item:
  link id:
    v: hpt-note.23.1
  text:
    v: Management Summary
  type:
    v: text

link id:
  v: hpt-note.24
text:
  v: TCA Date
type:
  v: group
item:
  extension:
    url:
      v: http://hl7.org/fhir/StructureDefinition/dateRule-my-core
    value: string
      v: futureDate
  link id:
    v: hpt-note.24.1
  text:
    v: Date
  type:
    v: dateTime

link id:
  v: hpt-note.25
text:
  v: Referral
type:
  v: group
item:
  link id:
    v: hpt-note.25.1
  text:
    v: Reason for Referral
  type:
    v: text
item:
  link id:
    v: hpt-note.25.2
  text:
    v: Spoken To
  type:
    v: string
item:
  link id:
    v: hpt-note.25.3
  text:
    v: Time of Referral made
  type:
    v: dateTime