FHIR IG analytics| Package | myhie.v4 |
| Resource Type | Composition |
| Id | hie-dc-comp-12345-140423.json |
| FHIR Version | R4 |
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FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "hie-dc-comp-12345-140423",
"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-CMP-2304000003"
},
"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\"><p><strong>Patient Name:</strong> Russell Johnson </p><p><strong>Medical Record Number:</strong> 123456789 </p><p><strong>Admission Date:</strong> 08 JAN 14 </p><p><strong>Discharge Date:</strong> 08 MAY 14 </p><p><strong>Attending Physician:</strong> Dr Gary Marshall </p><p><strong>Dictated by:</strong> Dr Gary Marhsall Primary </p><p><strong>Care Physician:</strong> Dr Dianna Miller Referring Physician: </p><p><strong>Consulting Physician(s):</strong> Dr Gary Marshall - hospitalist</p><p><strong>Condition on Discharge:</strong> stable </p><p><strong>Final Diagnosis: </strong></p><ol><li>RLL pneumonia</li><li>COPD exacerbation</li><li>mild CHF</li><li>osteoarthritis</li></ol><p><strong>Procedures:</strong> none </p><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. </li><li>Exacerbation of COPD: patient treated with inhaled and oral steroids, O2 at 2l/nc. On RA at time of discharge </li><li>Weakness and dehydration: secondary to pneumonia and COPD. Responded well to strengthening with PT and regular meals. </li></ol><p><strong>Discharge Medications:</strong></p><p> Zithromycin daily until gone, inhalers #of puffs</p><p><strong>Discharge Instructions:</strong> no activity restriction, regular diet, follow up in two to three weeks with regular physician.</p></div>"
}
},
{
"title": "Problem list",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11450-4",
"display": "Problem List"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">test%0A1%0A2%0A3</div>"
}
},
{
"title": "Vital Sign",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8716-3",
"display": "Vital Sign"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Value: </div>"
}
},
{
"title": "Respiratory Rate",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "9279-1",
"display": "Respiratory Rate"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Respiratory Rate: 80/min</div>"
}
},
{
"title": "Heart Rate",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8867-4",
"display": "Heart Rate"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Heart Rate: 90/min</div>"
}
},
{
"title": "Oxygen saturation",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "2708-6",
"display": "Oxygen Saturation"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Oxygen Saturation: 98@</div>"
}
},
{
"title": "Body Temperature",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8310-5",
"display": "Body Temperature"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Body Temperature: 37'C</div>"
}
},
{
"title": "Systolic Pressure",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8480-6",
"display": "Systolic Pressure"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Systolic Pressure: 120mmHg</div>"
}
},
{
"title": "Diastolic Pressure",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "8462-4",
"display": "Diastolic Pressure"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Diastolic Pressure: 90mmHg</div>"
}
},
{
"title": "Pain Score",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "72514-3",
"display": "Pain Score"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pain Score: 4</div>"
}
},
{
"title": "Allergies And Intolerance",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "48765-2",
"display": "Allergies And Intolerance"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Patient allergic to:</p><p>1. Paracetamol</p><p>2. Peanut</p></div>"
}
},
{
"title": "Medication",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10160-0",
"display": "Medication"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Patient home medication:</p><p>1. T PCM 500mg PRN</p><p>2. T metformin 500mg BD</p><p>3. T amlodipine 10mg OD</p></div>"
}
},
{
"title": "Social History",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29762-2",
"display": "Social History"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">social%20history%20goes%20here%0A1%0A2%0A3</div>"
}
},
{
"title": "Family History",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10157-6",
"display": "Family History"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">family%20history%20goes%20here%0A1%0A2%0A3</div>"
}
},
{
"title": "Immunization History",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11369-6",
"display": "Immunization History"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">immunization%20hx%20goes%20here%0A1%0A2%0A3</div>"
}
},
{
"title": "Assessment",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "51848-0",
"display": "Assessment"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>Name : MUHAMAD LUTHFI BIN HAZLAMI <br/>Sample : 11 OCT 2022 11:48:16 <br/>IC/Passport : 201110101859 <br/>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 <br/>Age : 1 YEAR 11 MTH <br/>Gender : MALE</p><p>Validated & Reported By: Siti Zarinawati Binti Johari (Juruteknologi Makmal Perubatan U29) <br/>Validated On: 11 OCT 2022 14:53:54 <br/>Accessed & Printed By: (10.29.194.218) Accessed On: 11 OCT 2022, 17:26:13</p><br/><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></div>"
}
},
{
"title": "Care Plan",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "18776-5",
"display": "Care Plan"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">care%20plan%20goes%20here%0A1%0A2%0A3</div>"
}
},
{
"title": "Adverse Event",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "85893-6",
"display": "Adverse Event"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">adverse%20event%20goe%20shere%0A1%0A2%0A3</div>"
}
}
]
}