| Package | IdHIE.0v |
| Resource Type | Questionnaire |
| Id | q-tb-note |
| FHIR Version | R4 |
| Source | https://simplifier.net/resolve?scope=IdHIE.0v@0.0.1&canonical=http://fhir.hie.moh.gov.id/Questionnaire/q-tb-note |
| URL | http://fhir.hie.moh.gov.id/Questionnaire/q-tb-note |
| Version | 1.0.0 |
| Status | active |
| Date | 2023-07-05T03:44:13.9017419+00:00 |
| Name | QTbNote |
| Title | TB Clerking Template |
No resources found
No resources found
No narrative content found in resource
FHIR{
"resourceType": "Questionnaire",
"id": "q-tb-note",
"meta": {
"versionId": "3",
"lastUpdated": "2023-07-03T12:49:31.901+08:00",
"source": "#4cyS4XNkvUOq5plk"
},
"url": "http://fhir.hie.moh.gov.id/Questionnaire/q-tb-note",
"version": "1.0.0",
"name": "QTbNote",
"title": "TB Clerking Template",
"status": "active",
"date": "2023-07-05T03:44:13.9017419+00:00",
"item": [
{
"linkId": "tb-note.1",
"text": "Special Group",
"type": "group",
"item": [
{
"linkId": "tb-note.1.1",
"text": "TB Contact",
"type": "boolean"
},
{
"linkId": "tb-note.1.2",
"text": "Pregnancy",
"type": "boolean"
},
{
"linkId": "tb-note.1.3",
"text": "Other comorbids (e.g Diabetes Mellitus or Hypertension)",
"type": "boolean"
},
{
"linkId": "tb-note.1.4",
"text": "Immunocompromised (e.g. on immunosupressants / HIV)",
"type": "boolean"
},
{
"linkId": "tb-note.1.5",
"text": "Special Group Remarks",
"type": "text"
}
]
},
{
"linkId": "tb-note.2",
"text": "Past Medical / Surgical History",
"type": "group",
"item": [
{
"linkId": "tb-note.2.1",
"text": "Past Medical History",
"type": "text"
},
{
"linkId": "tb-note.2.2",
"text": "Past Surgical History",
"type": "text"
}
]
},
{
"linkId": "tb-note.3",
"text": "Medication History",
"type": "group",
"item": [
{
"linkId": "tb-note.3.1",
"text": "Medication Details",
"type": "text"
}
]
},
{
"linkId": "tb-note.4",
"text": "Social and Family History",
"type": "group",
"item": [
{
"linkId": "tb-note.4.2",
"text": "Social History",
"type": "text"
},
{
"linkId": "tb-note.4.1",
"text": "Family History",
"type": "text"
}
]
},
{
"linkId": "tb-note.5",
"text": "Symptoms",
"type": "group",
"item": [
{
"linkId": "tb-note.5.1",
"text": "Cough",
"type": "boolean"
},
{
"linkId": "tb-note.5.2",
"text": "Fever",
"type": "boolean"
},
{
"linkId": "tb-note.5.3",
"text": "Night Sweats",
"type": "boolean"
},
{
"linkId": "tb-note.5.4",
"text": "Haemoptysis",
"type": "boolean"
},
{
"linkId": "tb-note.5.5",
"text": "Weight loss",
"type": "boolean"
},
{
"linkId": "tb-note.5.6",
"text": "Chest pain",
"type": "boolean"
},
{
"linkId": "tb-note.5.7",
"text": "Shortness of breath",
"type": "boolean"
},
{
"linkId": "tb-note.5.8",
"text": "Lethargy",
"type": "boolean"
},
{
"linkId": "tb-note.5.9",
"text": "Symptoms Remark",
"type": "text"
}
]
},
{
"linkId": "tb-note.6",
"text": "History of Presenting Illness Summary",
"type": "group",
"item": [
{
"linkId": "tb-note.6.1",
"text": "Findings",
"type": "text"
}
]
},
{
"linkId": "tb-note.7",
"text": "Vital Signs",
"type": "group",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue-my-core",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue-my-core",
"valueInteger": 300
}
],
"linkId": "tb-note.7.1",
"code": [
{
"system": "http://loinc.org",
"code": "8480-6",
"display": "Systolic Blood Pressure"
}
],
"text": "Systolic Blood Pressure (mmHg)",
"type": "quantity",
"initial": [
{
"valueQuantity": {
"unit": "mmHg",
"system": "http://unitsofmeasure.org",
"code": "mm[Hg]"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue-my-core",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue-my-core",
"valueInteger": 250
}
],
"linkId": "tb-note.7.2",
"code": [
{
"system": "http://loinc.org",
"code": "8462-4",
"display": "Diastolic Blood Pressure"
}
],
"text": "Diastolic Blood Pressure (mmHg)",
"type": "quantity",
"enableWhen": [
{
"question": "tb-note.7.1",
"operator": "exists",
"answerBoolean": true
}
],
"initial": [
{
"valueQuantity": {
"unit": "mmHg",
"system": "http://unitsofmeasure.org",
"code": "mm[Hg]"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue-my-core",
"valueInteger": 0
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue-my-core",
"valueInteger": 400
}
],
"linkId": "tb-note.7.3",
"text": "Heart Rate (/min)",
"type": "quantity",
"initial": [
{
"valueQuantity": {
"unit": "/min",
"system": "http://unitsofmeasure.org",
"code": "/min"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue-my-core",
"valueInteger": 0
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue-my-core",
"valueInteger": 100
}
],
"linkId": "tb-note.7.4",
"text": "Body Temperature (°C)",
"type": "quantity",
"initial": [
{
"valueQuantity": {
"unit": "°C",
"system": "http://unitsofmeasure.org",
"code": "Cel"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue-my-core",
"valueInteger": 0
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue-my-core",
"valueInteger": 100
}
],
"linkId": "tb-note.7.5",
"text": "Oxygen Saturation (%)",
"type": "quantity",
"initial": [
{
"valueQuantity": {
"unit": "%",
"system": "http://unitsofmeasure.org",
"code": "%"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue-my-core",
"valueInteger": 0
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue-my-core",
"valueInteger": 80
}
],
"linkId": "tb-note.7.6",
"text": "Respiratory Rate (/min)",
"type": "quantity",
"initial": [
{
"valueQuantity": {
"unit": "/min",
"system": "http://unitsofmeasure.org",
"code": "/min"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueInteger": 1
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueInteger": 10
}
],
"linkId": "tb-note.7.7",
"text": "Pain score",
"type": "quantity"
}
]
},
{
"linkId": "tb-note.8",
"text": "Physical Examination",
"type": "group",
"item": [
{
"linkId": "tb-note.8.1",
"text": "Findings",
"type": "text"
}
]
},
{
"linkId": "tb-note.9",
"text": "Investigations / Special Test",
"type": "group",
"item": [
{
"linkId": "tb-note.9.1",
"text": "Findings",
"type": "text"
}
]
},
{
"linkId": "tb-note.10",
"text": "Imaging",
"type": "group",
"item": [
{
"linkId": "tb-note.10.1",
"text": "Chest X ray Intepretation",
"type": "text"
}
]
},
{
"linkId": "tb-note.11",
"text": "Diagnosis",
"type": "group",
"item": [
{
"linkId": "tb-note.11.1",
"text": "Diagnosis",
"type": "text"
}
]
},
{
"linkId": "tb-note.12",
"text": "Management / Treatment",
"type": "group",
"item": [
{
"linkId": "tb-note.12.1",
"text": "Management Summary",
"type": "text"
}
]
},
{
"linkId": "tb-note.13",
"text": "Notification of Infectious Disease",
"type": "group",
"item": [
{
"linkId": "tb-note.13.1",
"text": "Spoken To",
"type": "text"
},
{
"linkId": "tb-note.13.2",
"text": "Time of Notification",
"type": "dateTime"
}
]
},
{
"linkId": "tb-note.14",
"text": "TCA Date",
"type": "group",
"item": [
{
"linkId": "tb-note.14.1",
"text": "Date",
"type": "dateTime"
}
]
},
{
"linkId": "tb-note.15",
"text": "Referral",
"type": "group",
"item": [
{
"linkId": "tb-note.15.1",
"text": "Reason for Referral",
"type": "text"
},
{
"linkId": "tb-note.15.2",
"text": "Spoken To",
"type": "string"
},
{
"linkId": "tb-note.15.3",
"text": "Time of Referral",
"type": "dateTime"
}
]
}
]
}