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
<ServiceRequest xmlns="http://hl7.org/fhir">
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<lastUpdated value="2023-04-09T23:19:39.908+08:00"/>
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value="http://fhir.hie.moh.gov.my/StructureDefinition/ServiceRequest-my-core"/>
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value="http://terminology.hl7.org/CodeSystem/v3-Confidentiality"/>
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<status value="extensions"/>
<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 referral</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>
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<type value="PractitionerRole"/>
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<system value="http://fhir.hie.moh.gov.my/sid/mmc-no"/>
<value value="43217"/>
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<display value="Murusamy A/L Atharv"/>
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<system value="http://fhir.hie.moh.gov.my/sid/service-request-id"/>
<value value="HTJ-REF-2304000005"/>
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<status value="active"/>
<intent value="proposal"/>
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value="http://fhir.hie.moh.gov.my/CodeSystem/servicerequest-category-my-core"/>
<code value="3457005"/>
<display value="Patient referral"/>
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<priority value="routine"/>
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<display value="Hospital Referral Summary"/>
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<reference value="Patient/patient-sample"/>
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<reference value="Encounter/encounter-sample"/>
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<authoredOn value="2022-08-30T08:00:46.838+08:00"/>
<requester>
<type value="PractitionerRole"/>
<identifier>
<system value="http://fhir.hie.moh.gov.my/sid/mmc-no"/>
<value value="76212"/>
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<display value="Wong Ah Liu"/>
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<coding>
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value="http://fhir.hie.moh.gov.my/CodeSystem/schedule-type-my-core"/>
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<display value="Internal"/>
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<reference value="Organization/11-05060009"/>
<type value="Organization"/>
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<type value="PractitionerRole"/>
<identifier>
<system value="http://fhir.hie.moh.gov.my/sid/mmc-no"/>
<value value="12345"/>
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<display value="Arumugan A/L Aryan"/>
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<reasonReference>
<reference value="Condition/condition-sample"/>
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<supportingInfo id="Recipient">
<type value="PractitionerRole"/>
<display value="Zuraidah Binti Abu"/>
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<note>
<text
value="<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>"/>
</note>
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