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 TB Clerking Template

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

Questionnaire to guide tuberculosis clerking and documentation.

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. QTbNoteQuestionnaire to guide tuberculosis clerking and documentation.Questionnairehttp://fhir.hie.moh.gov.my/Questionnaire/q-tb-note#2.0.1
... tb-note.1Special Group0..1group
.... tb-note.1.1TB Contact0..1boolean
.... tb-note.1.2Pregnancy0..1boolean
.... tb-note.1.3Other Comorbids (e.g Diabetes Mellitus or Hypertension)0..1boolean
.... tb-note.1.4Immunocompromised (e.g. on Immunosupressants / HIV)0..1boolean
.... tb-note.1.5Special Group Remarks0..1text
... tb-note.2Past Medical / Surgical History0..1group
.... tb-note.2.1Past Medical History0..1text
.... tb-note.2.2Past Surgical History0..1text
... tb-note.3Medication History0..1group
.... tb-note.3.1Medication Details0..1text
... tb-note.4Social and Family History0..1group
.... tb-note.4.2Social History0..1text
.... tb-note.4.1Family History0..1text
... tb-note.5Symptoms0..1group
.... tb-note.5.1Cough0..1boolean
.... tb-note.5.2Fever0..1boolean
.... tb-note.5.3Night Sweats0..1boolean
.... tb-note.5.4Haemoptysis0..1boolean
.... tb-note.5.5Weight Loss0..1boolean
.... tb-note.5.6Chest Pain0..1boolean
.... tb-note.5.7Shortness of Breath0..1boolean
.... tb-note.5.8Lethargy0..1boolean
.... tb-note.5.9Symptoms Remark0..1text
... tb-note.6History of Presenting Illness Summary0..1group
.... tb-note.6.1Findings0..1text
... tb-note.7Vital Signs0..1group
.... tb-note.7.1Systolic Blood Pressure (mmHg)0..1quantityInitial Value: Quantity = ? mmHg
.... tb-note.7.2Diastolic Blood Pressure (mmHg)0..1quantityEnable When: tb-note.7.1 exists
Initial Value: Quantity = ? mmHg
.... tb-note.7.3Heart Rate (/min)0..1quantityInitial Value: Quantity = ? /min
.... tb-note.7.4Body Temperature (°C)0..1quantityInitial Value: Quantity = ? °C
.... tb-note.7.5Oxygen Saturation (%)0..1quantityInitial Value: Quantity = ? %
.... tb-note.7.6Respiratory Rate (/min)0..1quantityInitial Value: Quantity = ? /min
.... tb-note.7.7Pain score0..1quantity
... tb-note.8Physical Examination0..1group
.... tb-note.8.1Findings0..1text
... tb-note.9Investigations / Special Test0..1group
.... tb-note.9.1Findings0..1text
... tb-note.10Imaging0..1group
.... tb-note.10.1Chest X ray Intepretation0..1text
... tb-note.11Diagnosis0..1group
.... tb-note.11.1Diagnosis0..1text
... tb-note.12Management / Treatment0..1group
.... tb-note.12.1Management Summary0..1text
... tb-note.13Notification of Infectious Disease0..1group
.... tb-note.13.1Spoken To0..1text
.... tb-note.13.2Time of Notification0..1dateTime
... tb-note.14TCA Date0..1group
.... tb-note.14.1Date0..1dateTime
... tb-note.15Referral0..1group
.... tb-note.15.1Reason for Referral0..1text
.... tb-note.15.2Spoken To0..1string
.... tb-note.15.3Time of Referral0..1dateTime

doco Documentation for this format