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

HL7 FHIR Malaysia Core (MY Core) Implementation Guide - Local Development build (v2.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example QuestionnaireResponse: example-questionnaireresponse-NHSI-MYSJ-123

Generated Narrative: QuestionnaireResponse example-questionnaireresponse-NHSI-MYSJ-123

LinkIDTextDefinitionAnswerdoco
.. example-questionnaireresponse-NHSI-MYSJ-123Questionnaire:https://fhir.hie.moh.gov.my/Questionnaire/nhsi-my-core
... 1User Demographic
.... 1.1NameTest
.... 1.2MySejahtera ID123
.... 1.3Contact Number123
.... 1.4Type of Identificationnhsi-my-core 01: Ic Numbers
.... 1.5IC Number/Passport92100514552
.... 1.6GenderAdministrativeGender male: Male
.... 1.7Nationality123
.... 1.8AddressLOT 1655-10B, JALAN SAUJANA KAMPUNG SUNGAI RAMAL DALAM
.... 1.9Occupationnhsi-my-core 02: Professional
.... 1.10Ethnicitynhsi-my-core 01: Malay
.... 1.11Special Category of Populationnhsi-my-core 00: Not Applicable
.... 1.12Industrynhsi-my-core 02: Advertising & Market Research
.... 1.13Comorbidities PresentSNOMED CT 73211009: Diabetes Mellitus
.... 1.14Last Screening Date
..... 1.14.1Has the patient performed health screening before?true
..... 1.14.2If Yes:2022-11-16
... 2Assessments
.... 2.1Does the patient have any family history?true
..... 2.1.1If yes:
.... 2.2Does the patient have any medical history?true
..... 2.2.1If yes:
... 3Mental Health Assessments
.... 3.1In the past 2 weeks, how often does this patient:
..... 3.1.1Felt Down, depressed or hopelessnhsi-my-core 01: Several Days
..... 3.1.2Little interest to do thingsnhsi-my-core 01: Several Days
..... 3.1.3Trouble falling asleep/staying asleep or sleeping too muchnhsi-my-core 02: > 7 days
..... 3.1.4Felt tired or having little energynhsi-my-core 01: Several Days
..... 3.1.5Had poor appetite or over eatingnhsi-my-core 00: Not At All
..... 3.1.6Felt bad about himself/herself, felt like a failure or he/she has let his/her family downnhsi-my-core 03: Almost everyday
..... 3.1.7Trouble concentrating (e.g. watching television or reading newspaper)nhsi-my-core 00: Not At All
..... 3.1.8Moved slowly or fidgeted excessively that is noticeable by people around him/hernhsi-my-core 00: Not At All
..... 3.1.9Had thoughts that he/she would be better dead, or hurting yourselfnhsi-my-core 01: Several Days
..... 3.1.10Total Mental Health Test Scorenhsi-my-core 01: 5-9 : Mild Depression
.... 3.2In the last 2 weeks, indicate how difficult these problems made it for this patient
..... 3.2.1Do your work, take care of things at home, or get along with othersnhsi-my-core 02: Very difficult
... 4Lifestyle Health Assessment
.... 4.1Alcohol consumption
..... 4.1.1How often do you consume alcohol?nhsi-my-core 00: Never
..... 4.1.2How many alcoholic beverages do you consume in a day?nhsi-my-core 02: 5-6
..... 4.1.3How often within the last year,
...... 4.1.3.1Do you consume 6 or more drink in a day?nhsi-my-core 02: Once a month
...... 4.1.3.2Were you not able to stop drinking once started?nhsi-my-core 02: Once a month
...... 4.1.3.3Were you not able to perform normal activities due to drinking?nhsi-my-core 03: Weekly
...... 4.1.3.4You needed to drink first thing in the morning to get going after a heavy drinking session?nhsi-my-core 02: Once a month
...... 4.1.3.5That you felt guilt or remorse after drinking?nhsi-my-core 01: < Once a month
...... 4.1.3.6Were you unable to remember what happened the night before due to drinking?nhsi-my-core 02: Once a month
..... 4.1.4Have you or someone else been injured because of your drinking?nhsi-my-core 02: Yes, during last year
..... 4.1.5Has a relative, friend, doctor, been concerned about your drinking habits?nhsi-my-core 00: No
..... 4.1.6Total Alcohol Consumption Test Scorenhsi-my-core 01: 8-12 Moderate Risk
.... 4.2Smoking Status
..... 4.2.1Does the patient smoke?true
..... 4.2.2Cigarettes per Day1
..... 4.2.3Years of Smoking12
..... 4.2.4Total pack-years1
... 5Clinical Parameters
.... 5.1Anthropometry: Height168 cm
.... 5.2Anthropometry: Weight58 kg
.... 5.3Anthropometry: Waistline30 cm
.... 5.4BMI calculation30 kg/m2
.... 5.5BMI Outcomenhsi-my-core 03: Overweight (25-29.9)
.... 5.6Vital Signs: Blood Pressure (systolic)120 mm[Hg]
.... 5.7Vital Signs: Blood Pressure (diastolic)90 mm[Hg]
.... 5.8Vital Signs: Pulse Rate80 /min
.... 5.9Blood Pressure Outcomenhsi-my-core 02: Normal (Systolic <130,Diastolic <85)
.... 5.10Point of Care Testing: Blood Glucose
..... 5.10.1Fasting12 mmol/L
..... 5.10.2Random12 mmol/L
..... 5.10.3Blood Glucose Outcomenhsi-my-core 02: Normal Fasting (<5.6)
.... 5.11Point of Care Testing: Blood Cholesterol
..... 5.11.1Fasting12 mmol/L
..... 5.11.2Random12 mmol/L
..... 5.11.3Blood Cholesterol Outcomenhsi-my-core 01: High >= 5.2 mmol/L
... 6Advanced Health Screening (Optional)
.... 6.1Cardiovascular
.... 6.2Gastrointestinal
.... 6.3Genitourinary
.... 6.4Locomotor
.... 6.5Neurological
.... 6.6ENT Symptoms
.... 6.7Dermatology
... 7Advanced Systemic Examination (Optional)
.... 7430591698512General Appearancenhsi-my-core 01: Abnormal
..... 9491690640065If Abnormal:nhsi-my-core 02: Cyanosed
.... 9385492769029Hands and Armsnhsi-my-core 01: Abnormal
..... 2706469979386If Abnormal:nhsi-my-core 05: Dupuytren’s contracture
.... 803255584502Headnhsi-my-core 01: Abnormal
..... 2706057387357If Abnormal:nhsi-my-core 03: Psoriatic plaque
.... 5438686906842Necknhsi-my-core 01: Abnormal
..... 8525967233111If Abnormal:nhsi-my-core 02: Trachea Deviation
.... 6320853137177Facenhsi-my-core 01: Abnormal
..... 3567829538338If Abnormal:nhsi-my-core 06: Increase of facial hair
.... 2775452197874Mouthnhsi-my-core 00: Normal
..... 2293927557638If Abnormal, Lips:nhsi-my-core 02: Stomatitis
..... 4080959756844If Abnormal, Gums:nhsi-my-core 01: Gingvitis
..... 9937565309207If Abnormal, Tongue:nhsi-my-core 04: Leukplakia
.... 681882410657Ears, Nose, Throatnhsi-my-core 01: Abnormal
..... 1009194092473If Abnormal, Ears:nhsi-my-core 01: Bleeding
..... 5071830545688If Abnormal, Nose:nhsi-my-core 01: Epistaxis
..... 1032584307566If Abnormal, Throat:nhsi-my-core 03: Deviated uvula
.... 1760871504781Eyesnhsi-my-core 01: Abnormal
..... 2830264276824If Abnormal, General:nhsi-my-core 02: Squint
..... 9200420167241If Abnormal, Conjunctiva:nhsi-my-core 01: Pallor
..... 3896132461914If Abnormal, Cornea:nhsi-my-core 02: Kaiser Fleischer's ring (Wilson Disease)
.... 4541398644599Fundoscopynhsi-my-core 00: Normal
..... 4508425091768If Abnormal, General:nhsi-my-core 02: Others
..... 3275429148998If Abnormal, Optic Discnhsi-my-core 01: Swollen
..... 87716190119If Abnormal, Retina:nhsi-my-core 02: Arteriovenous nicking
..... 1106310017866If Abnormal, Macula:nhsi-my-core 01: Exudates
.... 7802596122190Ishihara Chart:nhsi-my-core 02: Abnormal
.... 1772552914755Snellen Eye Chart Score
..... 5634044053426Snellen Eye Chart Right eye With Lensnhsi-my-core 01: 6/60
..... 6868904614360Snellen Eye Chart Right eye Without Lensnhsi-my-core 02: 6/36
..... 9535262095025Snellen Eye Chart Left eye With Lensnhsi-my-core 02: 6/36
..... 3784286555747Snellen Eye Chart Left eye Without Lensnhsi-my-core 02: 6/36
.... 4357973483106Cardiorespiratory Examinationnhsi-my-core 01: Abnormal
..... 3684125820499Cardiorespiratory Examination, inspection:nhsi-my-core 03: Peripheral edema
..... 1021145880907Cardiorespiratory Examination, palpation:nhsi-my-core 01: Tracheal Deviation
..... 5331561684920Cardiorespiratory Examination, percussion:nhsi-my-core 01: Chest dullness
..... 9727586284871Cardiorespiratory Examination, auscultationnhsi-my-core 02: Crepitations
.... 3445180818234Abdominal Examinationnhsi-my-core 01: Abnormal
..... 1295584939146Abdominal Examination, inspection:nhsi-my-core 03: Prominent viens
..... 6163894014798Abdominal Examination, palpationnhsi-my-core 01: Mass
..... 450925187844Abdominal Examination, percussion:nhsi-my-core 01: Shufting dullness
..... 9695659964510Abdominal Examination, auscultation:nhsi-my-core 02: Bruits
...... 3097284117717Bowel Soundnhsi-my-core 02: Absence
..... 896081526011Abdominal Examination, otherfree text
.... 8660013226797Breast Examinationnhsi-my-core 01: Abnormal
..... 2152650190448Breast Examination, inspection:nhsi-my-core 02: Scars
..... 5834188726294Breast Examination, palpation
...... 7571418373717Lumptrue
....... 8412518064517To state position, size, shape, consistency, overlying skin changes and mobilityfree text
...... 7708835727325Breast Examination, tendernesstrue
..... 7928508760431Breast Examination, lymph nodetrue
...... 5584007098886If yes, state locationfree text
..... 7966899757129Breast Examination, otherfree text
.... 4960397935179Genital Examinationnhsi-my-core 00: Normal
..... 129761420416If Abnormal:nhsi-my-core 01: Skin lesion
.... 6294648899702Musculoskeletal Examinationnhsi-my-core 01: Abnormal
..... 6506163486097If Abnormal:[not stated] 01: Muscle wasting
.... 8529069579767Neurological Examinationnhsi-my-core 00: Normal
..... 2933999220096Neurological Examination, motornhsi-my-core 01: Right Upper Limb
...... 5139376034252Neurological Examination, muscle tonenhsi-my-core 02: Hypotonia
...... 2810983082307Neurological Examination, muscle powernhsi-my-core 01: 1
..... 9525382653281Neurological Examination, reflexesnhsi-my-core 02: Left Upper Limb
...... 1871500398585Neurological Examination, hyperreflex/hyporeflexnhsi-my-core 01: Hyperreflex
..... 3739755767869Neurological Examination, babinskinhsi-my-core 02: Absent
..... 208277417057Neurological Examination, sensationnhsi-my-core 02: Loss of pain sensation
..... 969352104031Neurological Examination, otherasd
... 8Further Investigations
.... 8.1Urine dipstick123
.... 8.2Urine FEME123
.... 8.3ECG123
.... 8.4Haemoglobin123
... 9Diagnosis
.... 9.1Normal Healthy individual?nhsi-my-core 02: At risk
.... 9.2Diagnosis
..... 9.2.1Display123
..... 9.2.2Code123
..... 9.2.3Code System123
.... 9.3Provisional diagnosis
..... 9.3.1Display123
..... 9.3.2Code123
..... 9.3.3Code System123
... 10Management
.... 10.1General management
.... 10.2Doctor’s notes123
.... 10.3Prescription
..... 10.3.1Any medication prescribed?
... 11Verified by
.... 11.1Officer incharge123
.... 11.2Registration Number/ IC number123

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