| Package | myhie.v4 |
| Resource Type | Questionnaire |
| Id | q-gl-initial |
| FHIR Version | R4 |
| Source | https://simplifier.net/resolve?scope=myhie.v4@1.0.0&canonical=http://fhir.hie.moh.gov.my/Questionnaire/q-gl-initial |
| URL | http://fhir.hie.moh.gov.my/Questionnaire/q-gl-initial |
| Status | active |
| Date | 2024-03-13T01:41:41.3395961+00:00 |
| Title | Initial Guarantee Letter |
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No narrative content found in resource
FHIR{
"resourceType": "Questionnaire",
"id": "q-gl-initial",
"url": "http://fhir.hie.moh.gov.my/Questionnaire/q-gl-initial",
"title": "Initial Guarantee Letter",
"status": "active",
"date": "2024-03-13T01:41:41.3395961+00:00",
"item": [
{
"linkId": "HEADER",
"text": "Header",
"type": "group",
"item": [
{
"linkId": "GE HOSP_CODE",
"text": "GE PROVIDER CODE",
"type": "string"
},
{
"linkId": "REQ_TYPE",
"text": "Request type",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"code": "PA",
"display": "Pre-Authorization Form /Initial GL request"
}
},
{
"valueCoding": {
"code": "EA",
"display": "Elective Admission"
}
}
]
},
{
"linkId": "REQ_DATE",
"text": "Current date & time stamp",
"type": "dateTime"
},
{
"linkId": "HOSP_CASENO",
"text": "Hospital admission case no",
"type": "string"
}
]
},
{
"linkId": "D1",
"text": "Details",
"type": "group",
"item": [
{
"linkId": "REC-ID",
"text": "REC-ID",
"type": "string",
"maxLength": 20
},
{
"linkId": "PATIENT",
"text": "Patient Name",
"type": "string",
"maxLength": 200
},
{
"linkId": "NEWIC",
"text": "IC (new)",
"type": "string",
"maxLength": 14
},
{
"linkId": "IDNUM",
"text": "IC (old / others)",
"type": "string",
"maxLength": 24
},
{
"linkId": "CLTSEX",
"text": "Sex",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"system": "http://hl7.org/fhir/administrative-gender",
"code": "male",
"display": "Male"
}
},
{
"valueCoding": {
"system": "http://hl7.org/fhir/administrative-gender",
"code": "female",
"display": "Female"
}
}
]
},
{
"linkId": "CLTAGE",
"text": "Age of Patient",
"type": "string",
"maxLength": 3
},
{
"linkId": "POLICY_NO",
"text": "Policy No",
"type": "string",
"maxLength": 10
},
{
"linkId": "HOSP_CONTACT",
"text": "Hospital contact number",
"type": "string",
"maxLength": 20
},
{
"linkId": "HOSP_FAX",
"text": "Hospital Fax number",
"type": "string",
"maxLength": 20
},
{
"linkId": "ADMISSION_DATE",
"text": "Admission /Planned Admission Date & Time",
"type": "dateTime"
},
{
"linkId": "EXP_LOS",
"text": "Expected days of stay / Discharge date",
"type": "string",
"maxLength": 10
},
{
"linkId": "SYMPTOMS",
"text": "Symtoms /Conditions requiring admission",
"type": "text",
"maxLength": 500
},
{
"linkId": "BP_PULSE",
"text": "Patient's BP/Temp/Pulse",
"type": "text",
"maxLength": 200
},
{
"linkId": "CLT_AWARE",
"text": "How long is patient aware of the condition",
"type": "dateTime"
},
{
"linkId": "SYMPTOMS_DATE",
"text": "Date symptoms first appeared",
"type": "dateTime"
},
{
"linkId": "DATE_CONSULTED",
"text": "Date first consulted",
"type": "dateTime"
},
{
"linkId": "PREV_CONSULT",
"text": "Any previous consultation/treatment/hospitalization for this symptoms/illness or related conditions whether in this hospital or any other facilities",
"type": "boolean"
},
{
"linkId": "REFERRED",
"text": "Was the patient referred?",
"type": "boolean",
"enableWhen": [
{
"question": "PREV_CONSULT",
"operator": "=",
"answerBoolean": true
}
]
},
{
"linkId": "MEDICAL_HIST",
"text": "Referred hospital & details",
"type": "text",
"enableWhen": [
{
"question": "REFERRED",
"operator": "=",
"answerBoolean": true
}
],
"maxLength": 200
},
{
"linkId": "OUTPATIENT",
"text": "The condition can be managed under outpatient basis",
"type": "boolean"
},
{
"linkId": "REASON_NO_OP",
"text": "Reason of admission",
"type": "text",
"enableWhen": [
{
"question": "OUTPATIENT",
"operator": "=",
"answerBoolean": false
}
],
"maxLength": 200
},
{
"linkId": "ICD_CODE",
"text": "Diagnosis Description",
"type": "string",
"maxLength": 100
},
{
"linkId": "2nd_ICD",
"text": "Secondary Diagnosis code",
"type": "string",
"maxLength": 100
},
{
"linkId": "ICD_DESC",
"text": "Expected days of stay / Discharge date",
"type": "text",
"maxLength": 500
},
{
"linkId": "DIAGNOSIS_DATE",
"text": "Diagnosis confirmed on date",
"type": "dateTime"
},
{
"linkId": "ADVISED_DATE",
"text": "Date when doctor first advised the diagnosis to patient",
"type": "dateTime"
},
{
"linkId": "RELAPSE",
"text": "Any possibility of relapse",
"type": "boolean"
},
{
"linkId": "EST_COST",
"text": "Estimated Cost",
"type": "decimal"
},
{
"linkId": "ADMISSION_TYPE",
"text": "Type of admission",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"code": "IP",
"display": "Hospitalisation"
}
},
{
"valueCoding": {
"code": "DC",
"display": "Day Care"
}
},
{
"valueCoding": {
"code": "PR",
"display": "On patient's request"
}
}
]
},
{
"linkId": "ILLNESS_CONDITION",
"text": "selected illness/condition related to the diagnosis",
"type": "choice",
"answerOption": [
{
"valueCoding": {
"code": "a",
"display": "Pregnancy / Childbirth / Infertility / Caesarean section/ miscarriage Or any complications arising therefrom"
}
},
{
"valueCoding": {
"code": "b",
"display": "Congenital / Hereditary diseases"
}
},
{
"valueCoding": {
"code": "c",
"display": "Influence of Drugs / Alcohol"
}
},
{
"valueCoding": {
"code": "d",
"display": "Nervous / Mental / Emotional / Sleeping Disorder"
}
},
{
"valueCoding": {
"code": "e",
"display": "Cosmetic reason / Dental care / refractive errors correction"
}
},
{
"valueCoding": {
"code": "f",
"display": "AIDS / STD / VD / HIV"
}
},
{
"valueCoding": {
"code": "g",
"display": "Self-inflicted injuries / Violation of laws / Strike / Riots"
}
},
{
"valueCoding": {
"code": "h",
"display": "None of the above"
}
}
]
},
{
"linkId": "TREATMENT_PLAN",
"text": "Medical treatment, Investigation and Surgical procedure to be performed",
"type": "text",
"maxLength": 500
},
{
"linkId": "DIABETES_MELLITUS",
"text": "Does the patient have any Diabetes Mellitus condition?",
"type": "boolean"
},
{
"linkId": "DIABETES_SINCE_WHEN",
"text": "Date first diagnosed with Diabetes Mellitus",
"type": "dateTime",
"enableWhen": [
{
"question": "DIABETES_MELLITUS",
"operator": "=",
"answerBoolean": true
}
]
},
{
"linkId": "DIABETES_MED_DET",
"text": "1) doctor who first diagnosed (Name & Hosp) \n 2) usual treating doctor \n 3) current medications (name/dosage)",
"type": "text",
"enableWhen": [
{
"question": "DIABETES_MELLITUS",
"operator": "=",
"answerBoolean": true
}
],
"maxLength": 500
},
{
"linkId": "HYPERTENSION",
"text": "Does the patient have any hypertension condition?",
"type": "boolean"
},
{
"linkId": "HYPERTENSION_SINCE_WHEN",
"text": "Date first diagnosed with hypertension",
"type": "dateTime",
"enableWhen": [
{
"question": "HYPERTENSION",
"operator": "=",
"answerBoolean": true
}
]
},
{
"linkId": "HYPERTENSION_MED_DET",
"text": "1) doctor who first diagnosed (Name & Hosp) \n 2) usual treating doctor \n 3) current medications (name/dosage)",
"type": "text",
"enableWhen": [
{
"question": "HYPERTENSION",
"operator": "=",
"answerBoolean": true
}
],
"maxLength": 500
},
{
"linkId": "HEART_DISEASE",
"text": "Does the patient have any heart disease condition?",
"type": "boolean"
},
{
"linkId": "HEART_DISEASE_SINCE_WHEN",
"text": "Date first diagnosed with heart disease",
"type": "dateTime",
"enableWhen": [
{
"question": "HEART_DISEASE",
"operator": "=",
"answerBoolean": true
}
]
},
{
"linkId": "HEART_DIASEASE_MED_DET",
"text": "1) doctor who first diagnosed (Name & Hosp) \n 2) usual treating doctor \n 3) current medications (name/dosage)",
"type": "string",
"enableWhen": [
{
"question": "HEART_DISEASE",
"operator": "=",
"answerBoolean": true
}
],
"maxLength": 500
},
{
"linkId": "OTH_MEDICAL",
"text": "Other than above 3 specific illness. Does the patient have any other medical condition",
"type": "boolean"
},
{
"linkId": "OTH_MEDICAL_DET",
"text": "Other than above 3 specific illness. \n Doctor to provide other medical conditions if exist, if possible to provide medical conditions since date",
"type": "text",
"enableWhen": [
{
"question": "OTH_MEDICAL",
"operator": "=",
"answerBoolean": true
}
]
},
{
"linkId": "PREGNANT",
"text": "Was the patient pregnant at the time of hospitalization",
"type": "boolean"
},
{
"linkId": "ACCIDENTAL",
"text": "Accidental case",
"type": "boolean"
},
{
"linkId": "ACCIDENT_DATE",
"text": "Date & time of Accident",
"type": "dateTime",
"enableWhen": [
{
"question": "ACCIDENTAL",
"operator": "=",
"answerBoolean": true
}
]
},
{
"linkId": "ACCIDENT_DET",
"text": "Details of Accident",
"type": "text",
"enableWhen": [
{
"question": "ACCIDENTAL",
"operator": "=",
"answerBoolean": true
}
]
},
{
"linkId": "SURGICAL",
"text": "Surgery is required",
"type": "boolean"
},
{
"linkId": "SURGICAL_DATE",
"text": "Date of Surgical",
"type": "dateTime",
"enableWhen": [
{
"question": "SURGICAL",
"operator": "=",
"answerBoolean": true
}
]
},
{
"linkId": "INJURY_DESC",
"text": "Injury description",
"type": "text"
},
{
"linkId": "HOSP_DOCTOR_CODE",
"text": "Hospital doctor User Code",
"type": "string"
},
{
"linkId": "PHYSICIAN",
"text": "Name of Admitting / Treating doctor",
"type": "string"
},
{
"linkId": "PHYSICIAN_SPECIALTY",
"text": "Physician Specialty",
"type": "string"
},
{
"linkId": "GL Number",
"text": "GE Guarantee Letter Number",
"type": "string"
},
{
"linkId": "Patient_Consent",
"text": "Checklist - Patient's Consent and witness signature obtained",
"type": "boolean"
}
]
}
]
}