Actual or potential/near-miss event causing unintended physical injury resulting from or contributed to by medical care, a research study or other healthcare setting factors that requires additional monitoring, treatment, or hospitalization, or that results in death.

Risk of harmful or undesirable, physiological response which is unique to an individual and associated with exposure to a substance.

To differentiate between whether allergy assessment has been completed but no allergy found, or that allergy assessment was not done and status is unknown.

A booking of a healthcare event among patient(s), practitioner(s), related person(s) and/or device(s) for a specific date/time. This may result in one or more Encounter(s). For the Malaysian context, please refer to Scheduling & Appointment for scheduling integration guide.

Describes the intention of how one or more practitioners intend to deliver care for a particular patient, group or community for a period of time, possibly limited to care for a specific condition or set of conditions.

Describes the provision of healthcare provider products for a certain patient, therefore referring not only to the product, but containing in addition details of the provision, like date, time, amounts and participating organizations and persons. Main Usage of the ChargeItem is to enable the billing process and internal cost allocation.

Provides the properties that apply to the (billing) codes necessary to calculate costs and prices. The properties may differ largely depending on type and realm, therefore this resource gives only a rough structure and requires profiling for each type of billing code system.

A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. In the Malaysian context, this resource is also used to create sub-records for Maternal and Child Health, the Hajj medical screening program, and an International Patient Summary.

This profile is derived from the Composition (MY Core) profile, to delineate the contents of a general health screening. It was developed as a response to the Malaysian Ministry of Health's (MOH) National Health Screening Initiative (NHSI) to better manage non-communicable diseases (NCDs) through early detection and intervention.

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. In the Malaysian context, the code system of the Condition is not specified as it may be ICD-10 (International Classification of Diseases), ICD-11 or other local or international code systems. Currently the aim is to allow Continuity Of Care (COC) between facilities as one of the main priorities regardless of the code system used.

A record of a healthcare consumer's choices, which permits or denies identified recipient(s) or recipient role(s) to perform one or more actions within a given policy context, for specific purposes and periods of time. In the Malaysian context, the consent for information exchange between Ministry of Health facilities is obtained through an opt-out approach. Consent for decision-making in procedures, referrals and the creation of an International Patient Summary with QR sharing is obtained separately.

The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. This profile constrains the resource to represent diagnostic tests and procedure reports in a patient summary.

A collection of documents compiled for a purpose together with metadata that applies to the collection. In the Malaysian context, this resource is used to manage collections such as maternal health records (Ministry of Health pink book), child health records (Ministry of Health blue book), and pre-hajj medical screening records.

An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.

Significant health conditions for a person related to the patient relevant in the context of care for the patient. This includes health conditions of people closely related to the Patient, regardless of whether they are genetically related, especially in the context of infectious diseases. Previous experience of a condition in a close relation may also affect the patient's current experience and decision-making process, and should be explored.

Prospective warnings of potential issues when providing care to the patient.

Used to describe a single healthcare service or a category of services provided by an organization at a location. The location of the services could be virtual, as with telemedicine services.

Representation of the content produced in a DICOM imaging study. A study comprises a set of series, each of which includes a set of Service-Object Pair Instances (SOP Instances - images or other data) acquired or produced in a common context. A series is of only one modality (e.g. X-ray, CT, MR, ultrasound), but a study may have multiple series of different modalities.

Describes the event of a patient being administered a vaccination or a record of a vaccination as reported by a patient, a clinician or another party.

A patient's point-in-time set of recommendations (i.e. forecasting) according to a published schedule with optional supporting justification.

Invoice containing collected ChargeItems from an Account with calculated individual and total price for Billing purposes.

A list is a curated collection of resources that is flat, possibly ordered. List resources can be used in many places, including allergies, medications, alerts, family history, medical history, etc.

Details and position information for a physical place where services are provided and resources and participants may be stored, found, contained, or accommodated.

This resource is primarily used for the identification and definition of a medication for the purposes of prescribing, dispensing, and administering a medication as well as for making statements about medication use. In the Malaysian context, coding for medication is adopted from the Ministry of Health Pharmacy Information System (PhIS) database to standardize usage across the country.

Indicates that a medication product is to be or has been dispensed for a named person/patient. This includes a description of the medication product (supply) provided and the instructions for administering the medication. The medication dispense is the result of a pharmacy system responding to a medication order.

Supports creation of and querying for drug information including attributes such as drug classifications, images of medications, drug costs and/or coverages, etc. This resource can be used to return drug information as part of a formulary or a catalogue. In the Malaysian context, coding for medication is adopted from and constrained to the Malaysian Ministry of Health Pharmacy Information System (PhIS) master catalogue to standardize usage across the country.

An order or request for both supply of the medication and the instructions for administration of the medication to a patient. The resource is called "MedicationRequest" rather than "MedicationPrescription" or "MedicationOrder" to generalize the use across inpatient and outpatient settings, including care plans, etc., and to harmonize with workflow patterns. In the Malaysian context, coding for medication is adopted from the Ministry of Health Pharmacy Information System (PhIS) database to standardize usage across the country.

A record of a medication that is being consumed by a patient. May indicate that the patient is taking the medication now or has taken the medication in the past or will be taking the medication in the future. The source of this information can be the patient, significant other (such as a family member or spouse), or a clinician. In the Malaysian context, coding for medication is adopted from the Ministry of Health Pharmacy Information System (PhIS) database to standardize usage across the country.

This profile is derived from the Observation Panel (MY Core) resource.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource, constrained especially to document alerts in the setting of a dental service.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource, and has been constrained specifically to record developmental milestones in children.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource, and has been constrained specifically for foetal kick charting in pregnancy.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource, and constrained especially to record laboratory results.

This profile is derived from the base FHIR Observation resource constrained especially to record haemoglobin levels in pregnancy. In the Malaysian context, this facilitates consolidation of haemoglobin levels monitored during pregnancy in the Maternal Health Records (Ministry of Health pink book).

This profile is derived from the base FHIR Observation resource, constrained especially to record findings in an obstetrical ultrasound.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource, to define the different observation panel codes for the HIE in Malaysian Ministry of Health facilities.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource, constrained especially to record social history details.

This profile is derived from the Observation Panel (MY Core) profile, constrained to suit recording of a panel vital sign readings.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource.

This profile is derived from the base FHIR Observation resource.

A formally or informally recognized grouping of people or organizations formed for the purpose of achieving some form of collective action. In the Malaysian context, the clusterName and clusterFacility extensions allow further detailing of Ministry of Health facilities that are grouped into clusters for better facility management.

Defines an affiliation/assotiation/relationship between 2 distinct oganizations, that is not a part-of relationship/sub-division relationship. In the Malaysian context, this is used primarily to define the relationship between facilities that send and receive ServiceRequests, e.g. laboratory and imaging investigations, referrals and appointments.

Demographics and other administrative information about an individual or animal receiving care or other health-related services.

This resource provides the details including amount of a payment and allocates the payment items being paid.

A person who is directly or indirectly involved in the provisioning of healthcare.

A specific set of Roles/Locations/specialties/services that a practitioner may perform at an organization for a period of time. In the Malaysian context, resources often reference the PractitionerRole rather than Practitioner to highlight the Practitioner's role within that specific Organization.

An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.

A structured set of questions and their answers. The questions are ordered and grouped into coherent subsets, corresponding to the structure of the grouping of the questionnaire being responded to.

Information about a person that is involved in the care for a patient, but who is not the target of healthcare, nor has a formal responsibility in the care process.

A container for slots of time that may be available for booking appointments. For the Malaysian context, please refer to Scheduling & Appointment for the scheduling integration guide.

A record of a request for service such as diagnostic investigations, treatments, or operations to be performed.

A slot of time on a schedule that may be available for booking appointments. For the Malaysian context, please refer to Scheduling & Appointment for the scheduling integration guide.

A sample to be used for analysis. The resource contains specimen attributes usable for the laboratory results section and entry of a patient summary.

A kind of specimen with associated set of requirements.

Describes an activity that can be performed and tracks the state of completion of that activity. It is a representation that an activity should be or has been initiated, and eventually, represents the successful or unsuccessful completion of that activity.

A data type expressed using postal conventions (as opposed to GPS or other location definition formats), customised to suit Malaysian purposes.

Extension to reference additional relevant resources pertaining to the HealthcareService.

Extension to store district information in the form of a Codeable Concept.

Extension to store division information (For Sabah and Sarawak) value.

Extension to store state information in a Codeable Concept.

Extension to store sub division information (for Sabah and Sarawak) value.

Extension to add amended information of this clinical documentation.

Extension to determine whether this DiagnosticReport provides any external attachment.

Extension to add information related to the party who attested to this ServiceRequest.

Extension of the individual who recorded and updated the date

Extension to determine if the vaccine is a booster dose.

Extension for a ChargeItem to reference a ChargeItemDefinition.

Extension to store newborn details.

Extension to define the citizenship status of an individual.

Extension to determine position of the facility in the cluster of organizations as with Malaysian Ministry of Health facilities.

Extension to declare which cluster this organization belongs to.

Extension to define the date this section was created on.

Extension to clarify details about a disability.

Extension about the cautionary element of a drug.

Extension to document the drug form as per the Pharmacy Information System catalogue.

Extension about the general category of an individual's education level.

Extension about the outcome of an encounter.

Extension about the rating of an encounter.

Extension to classify the ethnicity of an individual.

Extension about an individidual foreigner category, e.g. undocumented migrant.

Extension to determine if this ServiceRequest requires a form attached to the request.

Extension to assign the set of form templates used by the Organization.

An extension to define the type of form this ServiceRequest uses when requesting this service.

An extension to state whether this Resource is based on a coded concept or is a non coded Resource.

Extension to classify whether this Encounter is from an internal or external referral.

Extension about the operational status of this List Resource.

Extension about the active period of this List Resource.

Extension to reference a currently active Encounter at the Location.

An extension to define where the Composition was recorded (Location Resource).

Extension to include Minimum inhibitory concentration (MIC) details in lab culture reports.

Extension to refer to the Organization Logo.

Extension to reference the MedicationKnowledge (Master Drug/Medication List) Resource.

Extension to define the settings of a particular Master Drug/Medication.

Extension to define the pack description template of this medication.

Extension to define the default property of a facility medication list template.

Extension to define this medication is orderd out of the default properties specified by the master Drug/Medication list.

Extension to define the mnemonic for a facility/organization.

Extension to define the individual monthly household income category.

Extension to define the nationality of a particular individual.

Extension to define the outcome diagnosis of a Virtual Consultation (for analytics).

Extension to further detail an OrganizationAffiliation outsource agreement.

Extension to define the maxium allowed outsource request in a day for an agreed outsource arrangement.

Extension to define the maximum quota of a agree outsource arrangement for a particular body/category region.

Extension to reference a SpecimenDefinition Resource.

Extension to categorize an individuals occupational sector

Extension to categorize the type of organization/facility category.

Extension to store which Pejabat Kesihatan Daerah (PKD) this facility/organization is under.

Extension to store the Global Positional System (GPS) properties of the facility.

Extension to define what classification of medication is allowed for a particular PractitionerRole.

Extension to define whether this PaymentReconciliation has been printed at least once.

Extension about the type of PaymentReconciliation.

Extension to store patient contact identifier.

Extension to categorise the patient according to status in relation to the Malaysian Armed Forces.

Extension to define the title of an individual.

Extension to declare whether this Encounter is directly created as part of a police case investigation.

Extension about the details of a line item in ChargeItem.

Extension to document the date that the DiagnosticReport is printed.

Extension about the main discipline that is performing the procedure.

Extension about the date the procedure was recorded.

Extension about the type of procedure session.

Extension to determine if this HealthcareService is allowed to be booked publicly (through patients/customer).

Extension to create reference to Questionnaire within the QuestionnaireResponse.

Extension that allows ServiceRequest to be able to reference Resources that led up to this record creation.

Extension about the individual's religious affiliation.

Whether an appointment booked under this Schedule requires approval from the provider side prior to booking.

Extension about the Global Positioning System (GPS) position for the service offered in a Schedule.

Extension about the type of schedule.

Extension to clarify whether a Schedule is allowed to be created for this Practitioner Role.

Extension to reference the custodian of this Resource.

Extension used in appointment for simple registration without having to creating a patient resource.

Extension to set the maximum quota allocated for a slot.

Extension to determine whether the lab test allows combining the same sample with another lab test.

Extension for patient/customer to rate an Encounter.

Extension to define the system tenant.

Extension to reference an affiliation transit centre.

Extension to determine the use context of a charge item.

Extension to determine the visit type.

Extension about the current status of the virtual consultation session.

Categorizing quality of pain

Active ingredient in a drug

Administrative gender in Malaysia

AdverseEvent event codes

Active ingredient in drug involved in allergy

Coding for specific allergy

Active ingredient in environment involved in allergy

Type of manifestation in an allergic reaction

Allergy negation statement

Components of audiology assessment

Components for assessment in aural rehabilitation

Components in cochlear implant assessment

Components in hearing aid assessment

Components in neonatal hearing screening

Bacterial susceptibility by Minimum Inhibitory Concentration (MIC)

Billing type

ChargeItemDefinition usage context type

Appointment cancellation reason

Child identification type

Malaysia city list

Clinic physiotherapy services

Position of facility within cluster of facilities

Composition category

Composition class

Composition event

Composition form type

Composition section

Composition type

Condition category

Consent category

Contract membership status

Contract membership type

Cooking demonstration type

Data type

PIK Death Certificate diagnosis code

Dental alert code

Dental code

Dental history alert

Dental procedure

Dentitian

Age group for fine motor assessment

Age group for gross motor assessment

Age group for social development assessment

Age group for speech development assessment

Developmental milestone

Device type

Extension to FHIR base DiagnosisRole ValueSet

Diagnostic procedures

Discharge disposition

Malaysia district list

Drug list

Drug allergy

Drug category

Drug cautionary

Drug dose form

Drug schedule

Special instruction list

Drug sub group

Drug trade names

Drug type

Education level in Malaysia

Encounter category

Additional class related to PIK code to extend the base FHIR CodeSystem encounter class

Front end value set for encounter class

Encounter outcome

Encounter outcome reason

Encounter priority

Encounter rating

Common ethnic groups in Malaysia

External referral source type

Components of Fat Analysis Panel using bioelectrical impedance analysis

Flag category

Foreigner type

Form template

Interpreting glucose level

Malaysian Physiotherapy Health Programs

Hospital-based physiotherapy services

HealthcareService characteristics

Malaysia imaging PIK code

Malaysia imaging modality PIK code

Malaysia imaging region PIK code

Status of ImmunizationRecommendation

Internal referral source type

Invoice status

Malaysia lab PIK code

Malaysia lab component PIK code

Malaysia lab method

Lab sub group

Location type

Location type front end

LOINC codes

Microorganisms/infectious agents

Minor procedure list

Monthly household income categories

Nationality

NCD VC report diagnoses

Nutrition Science Officer consultation reason

Nutritionist consultation reason

Anthropometry panel using LOINC code - 55418-8 Weight and Height tracking panel

Observation category for HIE

Bedside glucose measurement

Observation result interpretation

Components for obstetric ultrasound observation

Observation panel codes for HIE

Components for social history

Social history codes from Snomed CT

Components for blood pressure measurement panel under LOINC 85353-1

Components for heart rate measurement panel under LOINC 85353-1

Components for SpO2 measurement under LOINC 85353-1

Components for temperature measurement under LOINC 85353-1

Components for vital signs observation panel LOINC 85353-1

Malaysia occupation sector list

Operation status

Ophthalmic procedure list

Category of healthcare facility in Malaysian context

Categorization of organization for public viewing

Malaysian healthcare service organization type

Outsource category code

Outsource facility code

Quantifying frequency of pain

Payment type

Categorization of individual based on military category

Common title/prefix in Malaysia

PhIS medication frequency

PhIS medication route

PhIS medication unit of measure

Phlebotomist procedure

Malaysia postcode list

PractitionerRole list

Priority of request

Procedure category

Procedure code

Procedure complication

PIK procedure performer role

Procedure session type

Reason encounter occurred

Form required

Relationship of patient with related person

PIK code for relationship

Common religions in Malaysia

Revenue code

Schedule type

ServiceRequest category

ServiceRequest type

HealthcareService type

Side of body

Site of body

Source system

Specialty code

Malaysia specimen container type

Malaysia specimen type

Malaysian state list

Sub record type

Surface codes

Surface code

Codes indicating the type of action that is expected to be performed

Type of task

Task input type

Task nursing input

Task output type

Lab business status

Therapeutic Drug Monitoring recommendation

TDM sample type

Treatment procedure list

Malaysia childhood vaccine code system

Malaysia vaccine code system

Encounter visit type PIK code

Ward category

Ward class

Ward specialty

Active ingredient

Drug allergy codes

Active ingredient in environmental allergies

Audiology assessment

Components for aural rehabilitation

Components for cochlear implant assessment

Components for audiologic electrophysiology test

Audiology hearing aid assessment

Audiology neonatal hearing screening

Billing type

Appointment cancellation reason

Malaysian cities list

Clinic physiotherapy services

Position of facility in cluster

Composition category

Composition class

The specific clinical service or event being documented

Composition type

Condition category in Malaysia

Consent category

Contract membership type

Cooking demonstration category

Data type

Dental alert code

Dental code

Dental history alert

Dental procedure

Dentitian

Developmental milestone for fine motor

Developmental milestone for gross motor

Developmental milestone for social development

Developmental milestone for speech

Developmental milestone category

Device type

SMRP Diagnosis Code

Diagnostic procedure

Discharge disposition

Malaysia district list

Drug list

Specific drug allergy

Drug category

Drug cautionary

Drug dose form

Drug schedule

Drug special instruction list

Drug sub group

Drug trade name

Drug type

Education level for Malaysia

Encounter category

Encounter class list

Encounter outcome

Encounter outcome reason

Encounter rating

Ethnic group

External referral source type

Fat Analysis using bioelectrical impedance analysis

Flag category

Foreigner type - documented/illegal

Form template

Malaysia Physiotherapy Health Program list

Malaysia hospital-based physiotherapy services

HealthService characteristics

Malaysia imaging code system

PIK imaging modality code

Malaysia imaging region code system

Status of ImmunizationRecommendation

Internal referral source type

Malaysia PIK lab code system

Malaysia PIK lab component codes

Malaysia lab method

Malaysia lab sub group

Location type

Workflow setting

Minor procedure

Monthly household income

Nationality

NCD VC report diagnoses

Non-drug allergy code

Nutrition Science Officer consultation reason

Nutritionist consultation reason

Observation category

Additonal Observation panel code

Occupation sector

Operation status

Ophthalmic procedure

Category of healthcare organization in Malaysia

Type of healthcare organization in Malaysia

Depression and Anxiety Stress Scale questionnaire anxiety scoring

Audit-10 questionnaire outcome

Audit-C questionnaire outcome

Depression and Anxiety Stress Scale questionnaire depression scoring

General CVD risk questionnaire prediction

PHQ 9 questionnaire outcome

Depression and Anxiety Stress Scale questionnaire stress scoring

Whooley questionnaire outcome

Outsource facility

Payment type

Categorization of individual based on military category

Common titles/prefixes in Malaysia

PhIS medication frequency

PhIS medication route

PhIS medication unit of measure

Phlebotomist service

PIK procedure codes

Malaysia postcode

List of PractitionerRoles

Price component definition

Primary care type

NCD problem list

PIK procedure codes

Procedure category

Procedure complication

PIK procedure performer role

Procedure session type

Reason for encounter codes in Malaysia

Form type

Referral type

PIK codes for relationship

Malaysia common religions

Revenue code

Schedule type

Secondary care type of healthcare service

Codes for services

Outsource category

ServiceRequest category

Service type

Source system code

Specialty

Malaysia specimen container type

Specimen type

List of states in Malaysia

Sub-record type

Dentition surface

Dental surface description code

BusinessStatus codes indicating the type of action that is expected to be performed

Type of task

Task input type

Task output type

TDM recommendation

TDM sample type

Tertiary care healthcare service type in Malaysia

Treatment procedure

Malaysia vaccine codes

Encounter visit type PIK code

Ward category

Ward class

Appointment cancellation reason

The AUDIT-10 has 10 questions and the range of possible scores is from 0 to 40 where 0 indicates an abstainer who has never had any problems from alcohol, 1 to 7 suggests low risk consumption, 8 to 14 suggest harmful alcohol consumption and ≥15 Likelihood of alcohol dependence (moderate-severe alcohol use disorder)