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Source1

{
  "resourceType": "Composition",
  "id": "composition-myhix-sample",
  "meta": {
    "lastUpdated": "2023-04-06T22:58:30.149+08:00",
    "source": "sample",
    "security": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
        "code": "N"
      }
    ],
    "profile": [
      "http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core"
    ]
  },
  "extension": [
    {
      "url": "http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core",
      "valueReference": {
        "display": "Ward A"
      }
    }
  ],
  "identifier": {
    "system": "http://fhir.hie.moh.gov.my/sid/composition-id",
    "value": "HTJ-Hix-2304000001"
  },
  "status": "final",
  "type": {
    "coding": [
      {
        "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-type-my-core",
        "code": "18842-5",
        "display": "Discharge Summary Note"
      }
    ]
  },
  "category": [
    {
      "coding": [
        {
          "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core",
          "code": "LP72467-1",
          "display": "Discharge Summary Note"
        }
      ]
    }
  ],
  "subject": {
    "reference": "Patient/patient-sample"
  },
  "encounter": {
    "reference": "Encounter/encounter-sample"
  },
  "date": "2023-04-07T06:58:00.000+08:00",
  "author": [
    {
      "display": "Saw Lee Chin",
      "type": "PractitionerRole",
      "identifier": {
        "system": "http://fhir.hie.moh.gov.my/sid/mmc-no",
        "value": "64325"
      }
    }
  ],
  "attester": [
    {
      "mode": "professional",
      "party": {
        "display": "Kamal Bin Arifin",
        "type": "PractitionerRole",
        "identifier": {
          "system": "http://fhir.hie.moh.gov.my/sid/nsr-no",
          "value": "23312"
        }
      },
      "time": "2023-04-07T06:58:00.000+08:00"
    }
  ],
  "title": "Note",
  "custodian": {
    "reference": "Organization/11-05060009",
    "display": "HOSPITAL TUANKU JA'AFAR, SEREMBAN"
  },
  "event": [
    {
      "code": [
        {
          "coding": [
            {
              "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core",
              "code": "18842-5",
              "display": "Discharge Summary Note"
            }
          ]
        }
      ],
      "period": {
        "start": "2023-04-07T06:57:00.000+08:00"
      }
    }
  ],
  "section": [
    {
      "title": "Clinical Information",
      "code": {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "55752-0",
            "display": "Clinical Information"
          }
        ]
      },
      "text": {
        "status": "generated",
        "div": "<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>"
      }
    }
  ]
}