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
{
"resourceType" : "ServiceRequest",
"id" : "example-referral-summary-sr-myhix-sample",
"meta" : {
"lastUpdated" : "2023-04-09T23:19:39.908+08:00",
"source" : "sample",
"profile" : [
🔗 "http://fhir.hie.moh.gov.my/StructureDefinition/ServiceRequest-my-core"
],
"security" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
"code" : "N"
}
]
},
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: ServiceRequest example-referral-summary-sr-myhix-sample</b></p><a name=\"example-referral-summary-sr-myhix-sample\"> </a><a name=\"hcexample-referral-summary-sr-myhix-sample\"> </a><a name=\"example-referral-summary-sr-myhix-sample-en-US\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Last updated: 2023-04-09 23:19:39+0800; </p><p style=\"margin-bottom: 0px\">Information Source: sample</p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-ServiceRequest-my-core.html\">ServiceRequest (MY Core)</a></p><p style=\"margin-bottom: 0px\">Security Label: normal (Details: Confidentiality code N = 'normal')</p></div><blockquote><p><b>ExtensionAttester (MY Core)</b></p><ul><li>mode: professional</li><li>time: 2022-10-05 07:14:38+0800</li><li>party: Murusamy A/L Atharv (Identifier: <code>http://fhir.hie.moh.gov.my/sid/mmc-no</code>/43217)</li></ul></blockquote><p><b>identifier</b>: <code>http://fhir.hie.moh.gov.my/sid/service-request-id</code>/HTJ-REF-2304000005</p><p><b>status</b>: Active</p><p><b>intent</b>: Proposal</p><p><b>category</b>: <span title=\"Codes:{http://fhir.hie.moh.gov.my/CodeSystem/servicerequest-category-my-core 3457005}\">Patient\u00a0referral</span></p><p><b>priority</b>: Routine</p><p><b>code</b>: <span title=\"Codes:\">Hospital Referral Summary</span></p><p><b>subject</b>: <a href=\"Bundle-example-bundle-encounter-summary.html#Patient_patient-sample\">Bundle: type = transaction</a></p><p><b>encounter</b>: <a href=\"Bundle-example-bundle-encounter-summary.html#Encounter_encounter-sample\">Bundle: type = transaction</a></p><p><b>authoredOn</b>: 2022-08-30 08:00:46+0800</p><p><b>requester</b>: Wong Ah Liu (Identifier: <code>http://fhir.hie.moh.gov.my/sid/mmc-no</code>/76212)</p><p><b>performerType</b>: <span title=\"Codes:{http://fhir.hie.moh.gov.my/CodeSystem/schedule-type-my-core internal}\">Internal</span></p><p><b>performer</b>: </p><ul><li><a href=\"Organization/11-05060009\">Organization/11-05060009</a></li><li>Arumugan A/L Aryan (Identifier: <code>http://fhir.hie.moh.gov.my/sid/mmc-no</code>/12345)</li></ul><p><b>reasonReference</b>: <a href=\"Bundle-example-bundle-encounter-summary.html#Condition_condition-sample\">Bundle: type = transaction</a></p><p><b>supportingInfo</b>: Zuraidah Binti Abu</p><p><b>note</b>: <div xmlns="http://www.w3.org/1999/xhtml"><h2><strong>Allergies</strong></h2><ul><li><strong>Allergies and Other Adverse Reactions:</strong><p>Patient allergic to:</p><p>1. Paracetamol</p><p>2. Peanut</p></li></ul><h2><strong>Reason for Care</strong></h2><ul><li><strong>Hospital Admission Diagnosis:</strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li></ol></li><li><p><strong>History of Present Illness</strong></p><p>72 year old thin white male presented to emergency on 8 JAN 14 with shortness of breath, weakness and dehydration. Chest X-ray showed right lower lobe infiltrate, ABGs unremarkable. Pulse ox on RA was 79%25.</p><ol><li>Pneumonia: treated with ceftriaxone and azithromycin iv. Switched to PO after 72 hours.&nbsp;</li><li>Exacerbation of COPD: patient treated with inhaled and oral steroids, O2 at 2l/nc. On RA at time of discharge&nbsp;</li><li>Weakness and dehydration: secondary to pneumonia and COPD. Responded well to strengthening with PT and regular meals.&nbsp;</li></ol></li></ul><h2><strong>Other Condition Histories</strong></h2><ul><li><strong><strong>Active Problems:</strong></strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li><li>mild CHF</li><li>osteoarthritis</li></ol></li><li><strong>Discharge Diagnosis:</strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li><li>mild CHF</li><li>osteoarthritis</li></ol></li><li><strong>Resolved Problems:</strong>&nbsp;none</li><li><strong>List of Surgeries:</strong><ol><li>Craniotomy</li><li>Lumbar Puncture</li></ol></li></ul><h2><strong>Medication</strong></h2><ul><li><strong>Medications: </strong>Zithromycin daily until gone, inhalers #of puffs</li></ul><h2><strong>Relevant Studies</strong></h2><ul><li><strong>Results:</strong>&nbsp;</li></ul><p>Doctor : DR NURUL FAUZAN BIN MOHD PAUZI<br />Registration : 11 OCT 2022 11:48:16 D.O.B. : 10 NOV 2020<br />Clinic : KLINIK PAKAR<br />Completion : 11 OCT 2022 14:53:54</p><p>Validated &amp; Reported By: Siti Zarinawati Binti Johari (Juruteknologi Makmal Perubatan U29)<br />Validated On: 11 OCT 2022 14:53:54<br />Accessed &amp; Printed By: (10.29.194.218) Accessed On: 11 OCT 2022, 17:26:13</p><table><tbody><tr><th>Full Blood Count</th><th>Result</th><th>Unit</th><th>Ref Range</th></tr><tr><td>White Blood Cell Count</td><td>H 16.97</td><td>x 10^3uL</td><td>( 4.078 - 11.370 )</td></tr><tr><td>Red Blood Cell Count</td><td>L 3.85</td><td>x 10^6uL</td><td>( 4.53 - 5.95 )</td></tr><tr><td>Haemoglobin</td><td>LL 6.7</td><td>g/dL</td><td>( 13.5 - 17.4 )</td></tr><tr><td>Hematocrit</td><td>L 20.5</td><td>%25</td><td>( 40.1 - 50.6 )</td></tr><tr><td>Mean Cell Volume</td><td>L 53.2</td><td>fL</td><td>( 80.6 - 95.5 )</td></tr><tr><td>Mean Cell Haemoglobin</td><td>L 17.4</td><td>pg</td><td>( 26.9 - 32.3 )</td></tr><tr><td>Mean Cell Haemoglobin Concentration</td><td>32.7</td><td>g/dL</td><td>( 31.9 - 35.3 )</td></tr></tbody></table><ul><li><strong>Hospital Discharge:</strong>&nbsp;none</li><li><strong>Studies Summary:</strong>&nbsp;none</li></ul><h2><strong>Plans of Care</strong></h2><ul><li><strong>Care Plan:&nbsp;</strong>No activity restriction, regular diet, follow up in two to three weeks with regular physician.</li></ul></div></p></div>"
},
"extension" : [
{
"extension" : [
{
"url" : "mode",
"valueCode" : "professional"
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{
"url" : "time",
"valueDateTime" : "2022-10-05T07:14:38+08:00"
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{
"url" : "party",
"valueReference" : {
"type" : "PractitionerRole",
"identifier" : {
"system" : "http://fhir.hie.moh.gov.my/sid/mmc-no",
"value" : "43217"
},
"display" : "Murusamy A/L Atharv"
}
}
],
"url" : "http://fhir.hie.moh.gov.my/StructureDefinition/attester-my-core"
}
],
"identifier" : [
{
"system" : "http://fhir.hie.moh.gov.my/sid/service-request-id",
"value" : "HTJ-REF-2304000005"
}
],
"status" : "active",
"intent" : "proposal",
"category" : [
{
"coding" : [
{
"system" : "http://fhir.hie.moh.gov.my/CodeSystem/servicerequest-category-my-core",
"code" : "3457005",
"display" : "Patient\u00a0referral"
}
]
}
],
"priority" : "routine",
"code" : {
"coding" : [
{
"display" : "Hospital Referral Summary"
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]
},
"subject" : {
"reference" : "Patient/patient-sample"
},
"encounter" : {
"reference" : "Encounter/encounter-sample"
},
"authoredOn" : "2022-08-30T08:00:46.838+08:00",
"requester" : {
"type" : "PractitionerRole",
"identifier" : {
"system" : "http://fhir.hie.moh.gov.my/sid/mmc-no",
"value" : "76212"
},
"display" : "Wong Ah Liu"
},
"performerType" : {
"coding" : [
{
"system" : "http://fhir.hie.moh.gov.my/CodeSystem/schedule-type-my-core",
"code" : "internal",
"display" : "Internal"
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]
},
"performer" : [
{
"reference" : "Organization/11-05060009",
"type" : "Organization"
},
{
"type" : "PractitionerRole",
"identifier" : {
"system" : "http://fhir.hie.moh.gov.my/sid/mmc-no",
"value" : "12345"
},
"display" : "Arumugan A/L Aryan"
}
],
"reasonReference" : [
{
"reference" : "Condition/condition-sample"
}
],
"supportingInfo" : [
{
"id" : "Recipient",
"type" : "PractitionerRole",
"display" : "Zuraidah Binti Abu"
}
],
"note" : [
{
"text" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h2><strong>Allergies</strong></h2><ul><li><strong>Allergies and Other Adverse Reactions:</strong><p>Patient allergic to:</p><p>1. Paracetamol</p><p>2. Peanut</p></li></ul><h2><strong>Reason for Care</strong></h2><ul><li><strong>Hospital Admission Diagnosis:</strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li></ol></li><li><p><strong>History of Present Illness</strong></p><p>72 year old thin white male presented to emergency on 8 JAN 14 with shortness of breath, weakness and dehydration. Chest X-ray showed right lower lobe infiltrate, ABGs unremarkable. Pulse ox on RA was 79%25.</p><ol><li>Pneumonia: treated with ceftriaxone and azithromycin iv. Switched to PO after 72 hours. </li><li>Exacerbation of COPD: patient treated with inhaled and oral steroids, O2 at 2l/nc. On RA at time of discharge </li><li>Weakness and dehydration: secondary to pneumonia and COPD. Responded well to strengthening with PT and regular meals. </li></ol></li></ul><h2><strong>Other Condition Histories</strong></h2><ul><li><strong><strong>Active Problems:</strong></strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li><li>mild CHF</li><li>osteoarthritis</li></ol></li><li><strong>Discharge Diagnosis:</strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li><li>mild CHF</li><li>osteoarthritis</li></ol></li><li><strong>Resolved Problems:</strong> none</li><li><strong>List of Surgeries:</strong><ol><li>Craniotomy</li><li>Lumbar Puncture</li></ol></li></ul><h2><strong>Medication</strong></h2><ul><li><strong>Medications: </strong>Zithromycin daily until gone, inhalers #of puffs</li></ul><h2><strong>Relevant Studies</strong></h2><ul><li><strong>Results:</strong> </li></ul><p>Doctor : DR NURUL FAUZAN BIN MOHD PAUZI<br />Registration : 11 OCT 2022 11:48:16 D.O.B. : 10 NOV 2020<br />Clinic : KLINIK PAKAR<br />Completion : 11 OCT 2022 14:53:54</p><p>Validated & Reported By: Siti Zarinawati Binti Johari (Juruteknologi Makmal Perubatan U29)<br />Validated On: 11 OCT 2022 14:53:54<br />Accessed & Printed By: (10.29.194.218) Accessed On: 11 OCT 2022, 17:26:13</p><table><tbody><tr><th>Full Blood Count</th><th>Result</th><th>Unit</th><th>Ref Range</th></tr><tr><td>White Blood Cell Count</td><td>H 16.97</td><td>x 10^3uL</td><td>( 4.078 - 11.370 )</td></tr><tr><td>Red Blood Cell Count</td><td>L 3.85</td><td>x 10^6uL</td><td>( 4.53 - 5.95 )</td></tr><tr><td>Haemoglobin</td><td>LL 6.7</td><td>g/dL</td><td>( 13.5 - 17.4 )</td></tr><tr><td>Hematocrit</td><td>L 20.5</td><td>%25</td><td>( 40.1 - 50.6 )</td></tr><tr><td>Mean Cell Volume</td><td>L 53.2</td><td>fL</td><td>( 80.6 - 95.5 )</td></tr><tr><td>Mean Cell Haemoglobin</td><td>L 17.4</td><td>pg</td><td>( 26.9 - 32.3 )</td></tr><tr><td>Mean Cell Haemoglobin Concentration</td><td>32.7</td><td>g/dL</td><td>( 31.9 - 35.3 )</td></tr></tbody></table><ul><li><strong>Hospital Discharge:</strong> none</li><li><strong>Studies Summary:</strong> none</li></ul><h2><strong>Plans of Care</strong></h2><ul><li><strong>Care Plan: </strong>No activity restriction, regular diet, follow up in two to three weeks with regular physician.</li></ul></div>"
}
]
}