HL7 FHIR Malaysia Core (MY Core) Implementation Guide
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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-referral-summary-sr-myhix-template - JSON Representation

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{
  "resourceType" : "ServiceRequest",
  "id" : "example-referral-summary-sr-myhix-template",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2023-04-25T11:01:46.170+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-template</b></p><a name=\"example-referral-summary-sr-myhix-template\"> </a><a name=\"hcexample-referral-summary-sr-myhix-template\"> </a><a name=\"example-referral-summary-sr-myhix-template-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\">version: 1; Last updated: 2023-04-25 11:01:46+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>: &lt;div xmlns=&quot;http://www.w3.org/1999/xhtml&quot;&gt;&lt;h2&gt;&lt;strong&gt;Document Set&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;Document unique id: &lt;/strong&gt;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Document repository unique id:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Document title:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Document confidentiality:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Document creation time:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Parent document id:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Parent document relationship:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Custodian&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;OID:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Name:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Address:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Patient&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;Name:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Gender:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;DOB:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Race:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;MRN:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Address:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Phone home:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Phone office:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Fax:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Email address:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;National id:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Author&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;Name:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;MMC:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Facility OID:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Facility name:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Time:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Consultant&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;Name:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;MMC:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;NSR:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Facility OID:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Facility name:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Time:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Visit / EncounterAdmission date&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;Discharge date:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Visit id:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Time:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Assign doctor name:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Assign doctor:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;MMC:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Assign doctor facility OID:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Assign doctor facility name:&amp;nbsp;&lt;/strong&gt;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Service id:&amp;nbsp;&lt;/strong&gt;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Service name:&amp;nbsp;&lt;/strong&gt;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Allergies&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;Allergies and Other Adverse Reactions:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Reason for Care&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;Hospital Admission Diagnosis:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Other Condition Histories&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;Active Problems:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Discharge Diagnosis:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Resolved Problems:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;List of Surgeries:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Medication&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;Medications:&amp;nbsp;entry goes here&lt;/strong&gt;&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Relevant Studies&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;Results:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Hospital Discharge:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;Studies Summary:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Plans of Care&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;Care Plan:&amp;nbsp;&lt;/strong&gt;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;&lt;strong&gt;Correspondence Facility&lt;/strong&gt;&lt;/h2&gt;&lt;ul&gt;&lt;li&gt;&lt;strong&gt;OID:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;li&gt;&lt;strong&gt;NameAddress:&lt;/strong&gt;&amp;nbsp;entry goes here&lt;/li&gt;&lt;/ul&gt;&lt;/div&gt;</p></div>"
  },
  "extension" : [
    {
      "extension" : [
        {
          "url" : "mode",
          "valueCode" : "professional"
        },
        {
          "url" : "time",
          "valueDateTime" : "2022-10-05T07:14:38+08:00"
        },
        {
          "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"
      }
    ]
  },
  "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"
      }
    ]
  },
  "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>Document Set</strong></h2><ul><li><strong>Document unique id: </strong>entry goes here</li><li><strong>Document repository unique id:</strong>&nbsp;entry goes here</li><li><strong>Document title:</strong>&nbsp;entry goes here</li><li><strong>Document confidentiality:</strong>&nbsp;entry goes here</li><li><strong>Document creation time:</strong>&nbsp;entry goes here</li><li><strong>Parent document id:</strong>&nbsp;entry goes here</li><li><strong>Parent document relationship:</strong>&nbsp;entry goes here</li></ul><h2><strong>Custodian</strong></h2><ul><li><strong>OID:</strong>&nbsp;entry goes here</li><li><strong>Name:</strong>&nbsp;entry goes here</li><li><strong>Address:</strong>&nbsp;entry goes here</li></ul><h2><strong>Patient</strong></h2><ul><li><strong>Name:</strong>&nbsp;entry goes here</li><li><strong>Gender:</strong>&nbsp;entry goes here</li><li><strong>DOB:</strong>&nbsp;entry goes here</li><li><strong>Race:</strong>&nbsp;entry goes here</li><li><strong>MRN:</strong>&nbsp;entry goes here</li><li><strong>Address:</strong>&nbsp;entry goes here</li><li><strong>Phone home:</strong>&nbsp;entry goes here</li><li><strong>Phone office:</strong>&nbsp;entry goes here</li><li><strong>Fax:</strong>&nbsp;entry goes here</li><li><strong>Email address:</strong>&nbsp;entry goes here</li><li><strong>National id:</strong>&nbsp;entry goes here</li></ul><h2><strong>Author</strong></h2><ul><li><strong>Name:</strong>&nbsp;entry goes here</li><li><strong>MMC:</strong>&nbsp;entry goes here</li><li><strong>Facility OID:</strong>&nbsp;entry goes here</li><li><strong>Facility name:</strong>&nbsp;entry goes here</li><li><strong>Time:</strong>&nbsp;entry goes here</li></ul><h2><strong>Consultant</strong></h2><ul><li><strong>Name:</strong>&nbsp;entry goes here</li><li><strong>MMC:</strong>&nbsp;entry goes here</li><li><strong>NSR:</strong>&nbsp;entry goes here</li><li><strong>Facility OID:</strong>&nbsp;entry goes here</li><li><strong>Facility name:</strong>&nbsp;entry goes here</li><li><strong>Time:</strong>&nbsp;entry goes here</li></ul><h2><strong>Visit / EncounterAdmission date</strong></h2><ul><li><strong>Discharge date:</strong>&nbsp;entry goes here</li><li><strong>Visit id:</strong>&nbsp;entry goes here</li><li><strong>Time:</strong>&nbsp;entry goes here</li><li><strong>Assign doctor name:</strong>&nbsp;entry goes here</li><li><strong>Assign doctor:</strong>&nbsp;entry goes here</li><li><strong>MMC:</strong>&nbsp;entry goes here</li><li><strong>Assign doctor facility OID:</strong>&nbsp;entry goes here</li><li><strong>Assign doctor facility name:&nbsp;</strong>entry goes here</li><li><strong>Service id:&nbsp;</strong>entry goes here</li><li><strong>Service name:&nbsp;</strong>entry goes here</li></ul><h2><strong>Allergies</strong></h2><ul><li><strong>Allergies and Other Adverse Reactions:</strong>&nbsp;entry goes here</li></ul><h2><strong>Reason for Care</strong></h2><ul><li><strong>Hospital Admission Diagnosis:</strong>&nbsp;entry goes here</li></ul><h2><strong>Other Condition Histories</strong></h2><ul><li><strong>Active Problems:</strong>&nbsp;entry goes here</li><li><strong>Discharge Diagnosis:</strong>&nbsp;entry goes here</li><li><strong>Resolved Problems:</strong>&nbsp;entry goes here</li><li><strong>List of Surgeries:</strong>&nbsp;entry goes here</li></ul><h2><strong>Medication</strong></h2><ul><li><strong>Medications:&nbsp;entry goes here</strong></li></ul><h2><strong>Relevant Studies</strong></h2><ul><li><strong>Results:</strong>&nbsp;entry goes here</li><li><strong>Hospital Discharge:</strong>&nbsp;entry goes here</li><li><strong>Studies Summary:</strong>&nbsp;entry goes here</li></ul><h2><strong>Plans of Care</strong></h2><ul><li><strong>Care Plan:&nbsp;</strong>entry goes here</li></ul><h2><strong>Correspondence Facility</strong></h2><ul><li><strong>OID:</strong>&nbsp;entry goes here</li><li><strong>NameAddress:</strong>&nbsp;entry goes here</li></ul></div>"
    }
  ]
}