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

Generated Narrative: QuestionnaireResponse example-questionnaireresponse

LinkIDTextDefinitionAnswerdoco
.. example-questionnaireresponseQuestionnaire:https://fhir.hie.moh.gov.my/baseR4/Questionnaire/mynhs-my-core
... 1User Demographic
.... 1.1NameAbu
.... 1.2MySejahtera ID921005146620
.... 1.3Contact Number+60115640217
.... 1.4Type of Identificationquestionnaire-my-core 01: Ic Numbers
.... 1.5IC Number/Passport921005146620
.... 1.6GenderAdministrativeGender male: Male
.... 1.7NationalityMalaysia
.... 1.8AddressKAMPUNG LAMA SALAK TENGGARA
.... 1.9Occupationquestionnaire-my-core 02: Professional
.... 1.10Ethnicityquestionnaire-my-core 01: Malay
.... 1.11Special Category of Populationquestionnaire-my-core 00: Not Applicable
.... 1.12Industryquestionnaire-my-core 01: Accomodations
.... 1.13Comorbidities Present
.... 1.14Last Screening Date
..... 1.14.1Has the patient performed health screening before?true
..... 1.14.2If Yes:2022-08-03
... 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 hopelessquestionnaire-my-core 02: > 7 days
..... 3.1.2Little interest to do thingsquestionnaire-my-core 00: Not At All
..... 3.1.3Trouble falling asleep/staying asleep or sleeping too muchquestionnaire-my-core 03: Almost everyday
..... 3.1.4Felt tired or having little energyquestionnaire-my-core 00: Not At All
..... 3.1.5Had poor appetite or over eatingquestionnaire-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 downquestionnaire-my-core 01: Several Days
..... 3.1.7Trouble concentrating (e.g. watching television or reading newspaper)questionnaire-my-core 02: > 7 days
..... 3.1.8Moved slowly or fidgeted excessively that is noticeable by people around him/herquestionnaire-my-core 03: Almost everyday
..... 3.1.9Had thoughts that he/she would be better dead, or hurting yourselfquestionnaire-my-core 00: Not At All
..... 3.1.10Total Mental Health Test Scorequestionnaire-my-core 02: 10-14 : Moderate 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 othersquestionnaire-my-core 02: Very difficult
... 4Lifestyle Health Assessment
.... 4.1Alcohol consumption
..... 4.1.1How often do you consume alcohol?questionnaire-my-core 01: Once a month
..... 4.1.2How many alcoholic beverages do you consume in a day?questionnaire-my-core 03: 7-9
..... 4.1.3How often within the last year,
...... 4.1.3.1Do you consume 6 or more drink in a day?questionnaire-my-core 01: < Once a month
...... 4.1.3.2Were you not able to stop drinking once started?questionnaire-my-core 02: Once a month
...... 4.1.3.3Were you not able to perform normal activities due to drinking?questionnaire-my-core 03: Weekly
...... 4.1.3.4You needed to drink first thing in the morning to get going after a heavy drinking session?questionnaire-my-core 02: Once a month
...... 4.1.3.5That you felt guilt or remorse after drinking?questionnaire-my-core 02: Once a month
...... 4.1.3.6Were you unable to remember what happened the night before due to drinking?questionnaire-my-core 03: Weekly
..... 4.1.4Have you or someone else been injured because of your drinking?questionnaire-my-core 02: Yes, during last year
..... 4.1.5Has a relative, friend, doctor, been concerned about your drinking habits?questionnaire-my-core 01: Yes, but not last year
..... 4.1.6Total Alcohol Consumption Test Scorequestionnaire-my-core 02: >13 High Risk
.... 4.2Smoking Status
..... 4.2.1Does the patient smoke?true
..... 4.2.2Cigarettes per Day10
..... 4.2.3Years of Smoking10
..... 4.2.4Total pack-years10
... 5Clinical Parameters
.... 5.1Anthropometry: Height10 cm
.... 5.2Anthropometry: Weight10 kg
.... 5.3Anthropometry: Waistline10 cm
.... 5.4BMI calculation10 kg/m2
.... 5.5BMI Outcomequestionnaire-my-core 02: Normal Weight (18.5-24.9)
.... 5.6Vital Signs: Blood Pressure (systolic)10 mm[Hg]
.... 5.7Vital Signs: Blood Pressure (diastolic)10 mm[Hg]
.... 5.8Vital Signs: Pulse Rate10 /min
.... 5.9Blood Pressure Outcomequestionnaire-my-core 02: Normal (Systolic <130,Diastolic <85)
.... 5.10Point of Care Testing: Blood Glucose
..... 5.10.1Fasting10 mmol/L
..... 5.10.2Random10 mmol/L
..... 5.10.3Blood Glucose Outcomequestionnaire-my-core 03: Normal Random (<7.8)
.... 5.11Point of Care Testing: Blood Cholesterol
..... 5.11.1Fasting10 mmol/L
..... 5.11.2Random10 mmol/L
..... 5.11.3Blood Cholesterol Outcomequestionnaire-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)
.... 7.1General Appearancequestionnaire-my-core 01: Abnormal
..... 7.1.1If Abnormal:
.... 7.2Hands and Arms:questionnaire-my-core 00: Normal
..... 7.2.1If Abnormal:
.... 7.3Head, Ears, Eyes, Nose and Throatquestionnaire-my-core 01: Abnormal
..... 7.3.1If Abnormal:
.... 7.4Eyes:questionnaire-my-core 00: Normal
..... 7.4.1If Abnormal (Conjuntival):[not stated] : Pallor
..... 7.4.2If Abnormal (Sclera):
..... 7.4.3If Abnormal (Cornea):
.... 7.5Fundoscopyquestionnaire-my-core 00: Normal
..... 7.5.1If Abnormal:questionnaire-my-core 01: Absence of red reflex
..... 7.5.2Optic Discquestionnaire-my-core 01: Swollen
..... 7.5.3Retina
..... 7.5.4Macula
.... 7.6Snellen Eye Chart Score:questionnaire-my-core 00: Normal
..... 7.6.1If Abnormal (Right Eye):questionnaire-my-core 01: 60/6
..... 7.6.2If Abnormal (Left Eye):questionnaire-my-core 02: 36/6
.... 7.7Lips:questionnaire-my-core 01: Abnormal
..... 7.7.1If Abnormal (Lips):
..... 7.7.2If Abnormal (Gums)questionnaire-my-core 01: Gingivitis
.... 7.8Tongue:questionnaire-my-core 00: Normal
..... 7.8.1If Abnormal:
.... 7.9Neckquestionnaire-my-core 01: Abnormal
..... 7.9.1If Abnormal:
.... 7.10Cardiorespiratory Examinationquestionnaire-my-core 00: Normal
..... 7.10.1If Abnormal:
.... 7.11Abdominal Examinationquestionnaire-my-core 00: Normal
..... 7.11.1If Abnormal:
.... 7.12Genital Examinationquestionnaire-my-core 00: Normal
..... 7.12.1If Abnormal:
.... 7.13Musculoskeletal Examinationquestionnaire-my-core 01: Abnormal
..... 7.13.1If Abnormal:
.... 7.14Neurological Examinationquestionnaire-my-core 00: Normal
..... 7.14.1If Abnormal:
... 8Further Investigations
.... 8.1Urine dipstick10
.... 8.2Urine FEME10
.... 8.3ECG10
.... 8.4Haemoglobin10
... 9Diagnosis
.... 9.1Normal Healthy individual?questionnaire-my-core 01: No
.... 9.2Diagnosis
..... 9.2.1DisplayDengue NOS
..... 9.2.2Code 1D2Z
..... 9.2.3Code Systemhttp://hl7.org/fhir/sid/icd-11
.... 9.3Provisional diagnosis
..... 9.3.1DisplayHypertension NOS
..... 9.3.2CodeBA00.Z
..... 9.3.3Code Systemhttp://hl7.org/fhir/sid/icd-11
.... 9.3Provisional diagnosis
..... 9.3.1DisplayMonkeypox
..... 9.3.2Code1E71
..... 9.3.3Code Systemhttp://hl7.org/fhir/sid/icd-11
... 10Management
.... 10.1General management
.... 10.2Doctor’s notesThis note is a markdown It should save user entry formats
.... 10.3Prescription
..... 10.3.1Any medication prescribed?
... 11Verified by
.... 11.1Officer inchargeSaiful
.... 11.2Registration Number/ IC number81751

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