q-tb-note
type: Questionnaire
node role: treeRoot
id:
  v: q-tb-note
text:
  status:
    v: extensions
  div: Generated Narrative: Questionnaire q-tb-note LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> QTbNote Questionnaire to guide tuberculosis clerking and documentation. Questionnaire http://fhir.hie.moh.gov.my/Questionnaire/q-tb-note#2.0.1 #xD; tb-note.1 Special Group 0..1 group #xD; tb-note.1.1 TB Contact 0..1 boolean #xD; tb-note.1.2 Pregnancy 0..1 boolean #xD; tb-note.1.3 Other Comorbids (e.g Diabetes Mellitus or Hypertension) 0..1 boolean #xD; tb-note.1.4 Immunocompromised (e.g. on Immunosupressants / HIV) 0..1 boolean #xD; tb-note.1.5 Special Group Remarks 0..1 text #xD; tb-note.2 Past Medical / Surgical History 0..1 group #xD; tb-note.2.1 Past Medical History 0..1 text #xD; tb-note.2.2 Past Surgical History 0..1 text #xD; tb-note.3 Medication History 0..1 group #xD; tb-note.3.1 Medication Details 0..1 text #xD; tb-note.4 Social and Family History 0..1 group #xD; tb-note.4.2 Social History 0..1 text #xD; tb-note.4.1 Family History 0..1 text #xD; tb-note.5 Symptoms 0..1 group #xD; tb-note.5.1 Cough 0..1 boolean #xD; tb-note.5.2 Fever 0..1 boolean #xD; tb-note.5.3 Night Sweats 0..1 boolean #xD; tb-note.5.4 Haemoptysis 0..1 boolean #xD; tb-note.5.5 Weight Loss 0..1 boolean #xD; tb-note.5.6 Chest Pain 0..1 boolean #xD; tb-note.5.7 Shortness of Breath 0..1 boolean #xD; tb-note.5.8 Lethargy 0..1 boolean #xD; tb-note.5.9 Symptoms Remark 0..1 text #xD; tb-note.6 History of Presenting Illness Summary 0..1 group #xD; tb-note.6.1 Findings 0..1 text #xD; tb-note.7 Vital Signs 0..1 group #xD; tb-note.7.1 Systolic Blood Pressure (mmHg) 0..1 quantity Initial Value: Quantity = ? mmHg #xD; tb-note.7.2 Diastolic Blood Pressure (mmHg) 0..1 quantity Enable When: tb-note.7.1 exists Initial Value: Quantity = ? mmHg #xD; tb-note.7.3 Heart Rate (/min) 0..1 quantity Initial Value: Quantity = ? /min #xD; tb-note.7.4 Body Temperature (°C) 0..1 quantity Initial Value: Quantity = ? °C #xD; tb-note.7.5 Oxygen Saturation (%…
url:
  v: http://fhir.hie.moh.gov.my/Questionnaire/q-tb-note
version:
  v: 2.0.1
name:
  v: QTbNote
title:
  v: Questionnaire TB Clerking Template
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: Questionnaire to guide tuberculosis clerking and documentation.
item:
  link id:
    v: tb-note.1
  text:
    v: Special Group
  type:
    v: group
  item:
    link id:
      v: tb-note.1.1
    text:
      v: TB Contact
    type:
      v: boolean
  item:
    link id:
      v: tb-note.1.2
    text:
      v: Pregnancy
    type:
      v: boolean
  item:
    link id:
      v: tb-note.1.3
    text:
      v: Other Comorbids (e.g Diabetes Mellitus or Hypertension)
    type:
      v: boolean
  item:
    link id:
      v: tb-note.1.4
    text:
      v: Immunocompromised (e.g. on Immunosupressants / HIV)
    type:
      v: boolean
  item:
    link id:
      v: tb-note.1.5
    text:
      v: Special Group Remarks
    type:
      v: text
item:
  link id:
    v: tb-note.2
  text:
    v: Past Medical / Surgical History
  type:
    v: group
  item:
    link id:
      v: tb-note.2.1
    text:
      v: Past Medical History
    type:
      v: text
  item:
    link id:
      v: tb-note.2.2
    text:
      v: Past Surgical History
    type:
      v: text
item:
  link id:
    v: tb-note.3
  text:
    v: Medication History
  type:
    v: group
  item:
    link id:
      v: tb-note.3.1
    text:
      v: Medication Details
    type:
      v: text
item:
  link id:
    v: tb-note.4
  text:
    v: Social and Family History
  type:
    v: group
  item:
    link id:
      v: tb-note.4.2
    text:
      v: Social History
    type:
      v: text
  item:
    link id:
      v: tb-note.4.1
    text:
      v: Family History
    type:
      v: text
item:
  link id:
    v: tb-note.5
  text:
    v: Symptoms
  type:
    v: group
  item:
    link id:
      v: tb-note.5.1
    text:
      v: Cough
    type:
      v: boolean
  item:
    link id:
      v: tb-note.5.2
    text:
      v: Fever
    type:
      v: boolean
  item:
    link id:
      v: tb-note.5.3
    text:
      v: Night Sweats
    type:
      v: boolean
  item:
    link id:
      v: tb-note.5.4
    text:
      v: Haemoptysis
    type:
      v: boolean
  item:
    link id:
      v: tb-note.5.5
    text:
      v: Weight Loss
    type:
      v: boolean
  item:
    link id:
      v: tb-note.5.6
    text:
      v: Chest Pain
    type:
      v: boolean
  item:
    link id:
      v: tb-note.5.7
    text:
      v: Shortness of Breath
    type:
      v: boolean
  item:
    link id:
      v: tb-note.5.8
    text:
      v: Lethargy
    type:
      v: boolean
  item:
    link id:
      v: tb-note.5.9
    text:
      v: Symptoms Remark
    type:
      v: text

link id:
  v: tb-note.6
text:
  v: History of Presenting Illness Summary
type:
  v: group
item:
  link id:
    v: tb-note.6.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: tb-note.7
text:
  v: 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: tb-note.7.1
  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: tb-note.7.2
  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: tb-note.7.1
    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: tb-note.7.3
  text:
    v: Heart Rate (/min)
  type:
    v: quantity
  initial:
    value: Quantity
      unit:
        v: /min
      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: tb-note.7.4
  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: 100
  link id:
    v: tb-note.7.5
  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: 80
  link id:
    v: tb-note.7.6
  text:
    v: Respiratory Rate (/min)
  type:
    v: quantity
  initial:
    value: Quantity
      unit:
        v: /min
      system:
        v: http://unitsofmeasure.org
      code:
        v: /min
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: 10
  link id:
    v: tb-note.7.7
  text:
    v: Pain score
  type:
    v: quantity

link id:
  v: tb-note.8
text:
  v: Physical Examination
type:
  v: group
item:
  link id:
    v: tb-note.8.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: tb-note.9
text:
  v: Investigations / Special Test
type:
  v: group
item:
  link id:
    v: tb-note.9.1
  text:
    v: Findings
  type:
    v: text

link id:
  v: tb-note.10
text:
  v: Imaging
type:
  v: group
item:
  link id:
    v: tb-note.10.1
  text:
    v: Chest X ray Intepretation
  type:
    v: text

link id:
  v: tb-note.11
text:
  v: Diagnosis
type:
  v: group
item:
  link id:
    v: tb-note.11.1
  text:
    v: Diagnosis
  type:
    v: text

link id:
  v: tb-note.12
text:
  v: Management / Treatment
type:
  v: group
item:
  link id:
    v: tb-note.12.1
  text:
    v: Management Summary
  type:
    v: text

link id:
  v: tb-note.13
text:
  v: Notification of Infectious Disease
type:
  v: group
item:
  link id:
    v: tb-note.13.1
  text:
    v: Spoken To
  type:
    v: text
item:
  link id:
    v: tb-note.13.2
  text:
    v: Time of Notification
  type:
    v: dateTime

link id:
  v: tb-note.14
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: tb-note.14.1
  text:
    v: Date
  type:
    v: dateTime

link id:
  v: tb-note.15
text:
  v: Referral
type:
  v: group
item:
  link id:
    v: tb-note.15.1
  text:
    v: Reason for Referral
  type:
    v: text
item:
  link id:
    v: tb-note.15.2
  text:
    v: Spoken To
  type:
    v: string
item:
  link id:
    v: tb-note.15.3
  text:
    v: Time of Referral
  type:
    v: dateTime