FHIR IG analytics| Package | myhie.v4 |
| Resource Type | QuestionnaireResponse |
| Id | example-NHSI QR.json |
| FHIR Version | R4 |
No resources found
No resources found
No narrative content found in resource
FHIR
FHIRsmith{
"resourceType": "QuestionnaireResponse",
"id": "MYSJ-123",
"meta": {
"source": "http://peka40.moh.gov.my",
"profile": [
"http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse"
]
},
"extension": [
{
"url": "http://fhir.hie.moh.gov.my/StructureDefinition/service-provider-my-core",
"valueReference": {
"reference": "Organization/PH"
}
}
],
"identifier": {
"value": "MYSJ-123"
},
"questionnaire": "https://fhir.hie.moh.gov.my/baseR4/Questionnaire/nhsi-my-core",
"status": "completed",
"subject": {
"reference": "Patient/example-NHSI-patient"
},
"authored": "2022-11-16T04:40:46.883Z",
"author": {
"text": "Dr Susan"
},
"item": [
{
"linkId": "1",
"text": "User Demographic",
"item": [
{
"linkId": "1.1",
"text": "Name",
"answer": [
{
"valueString": "Test"
}
]
},
{
"linkId": "1.2",
"text": "MySejahtera ID",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "1.3",
"text": "Contact Number",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "1.4",
"text": "Type of Identification",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Ic Numbers"
}
}
]
},
{
"linkId": "1.5",
"text": "IC Number/Passport",
"answer": [
{
"valueString": "92100514552"
}
]
},
{
"linkId": "1.6",
"text": "Gender",
"answer": [
{
"valueCoding": {
"system": "http://hl7.org/fhir/administrative-gender",
"code": "male",
"display": "Male"
}
}
]
},
{
"linkId": "1.7",
"text": "Nationality",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "1.8",
"text": "Address",
"answer": [
{
"valueString": "LOT 1655-10B, JALAN SAUJANA KAMPUNG SUNGAI RAMAL DALAM"
}
]
},
{
"linkId": "1.9",
"text": "Occupation",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Professional"
}
}
]
},
{
"linkId": "1.10",
"text": "Ethnicity",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Malay"
}
}
]
},
{
"linkId": "1.11",
"text": "Special Category of Population",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "00",
"display": "Not Applicable"
}
}
]
},
{
"linkId": "1.12",
"text": "Industry",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Advertising & Market Research"
}
}
]
},
{
"linkId": "1.13",
"text": "Comorbidities Present",
"answer": [
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "73211009",
"display": "Diabetes Mellitus"
}
}
]
},
{
"linkId": "1.14",
"text": "Last Screening Date",
"item": [
{
"linkId": "1.14.1",
"text": "Has the patient performed health screening before?",
"answer": [
{
"valueBoolean": true
}
]
},
{
"linkId": "1.14.2",
"text": "If Yes:",
"answer": [
{
"valueDate": "2022-11-16"
}
]
}
]
}
]
},
{
"linkId": "2",
"text": "Assessments",
"item": [
{
"linkId": "2.1",
"text": "Does the patient have any family history?",
"answer": [
{
"valueBoolean": true,
"item": [
{
"linkId": "2.1.1",
"text": "If yes:",
"answer": [
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "38341003",
"display": "Hypertension"
}
},
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "73211009",
"display": "Diabetes Mellitus"
}
},
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "13644009",
"display": "Hypercholesterolemia"
}
}
]
}
]
}
]
},
{
"linkId": "2.2",
"text": "Does the patient have any medical history?",
"answer": [
{
"valueBoolean": true,
"item": [
{
"linkId": "2.2.1",
"text": "If yes:",
"answer": [
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "13644009",
"display": "Hypercholesterolemia"
}
},
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "73211009",
"display": "Diabetes Mellitus"
}
},
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "56265001",
"display": "Coronary Heart Disease"
}
}
]
}
]
}
]
}
]
},
{
"linkId": "3",
"text": "Mental Health Assessments",
"item": [
{
"linkId": "3.1",
"text": "In the past 2 weeks, how often does this patient:",
"item": [
{
"linkId": "3.1.1",
"text": "Felt Down, depressed or hopeless",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Several Days"
}
}
]
},
{
"linkId": "3.1.2",
"text": "Little interest to do things",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Several Days"
}
}
]
},
{
"linkId": "3.1.3",
"text": "Trouble falling asleep/staying asleep or sleeping too much",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "> 7 days"
}
}
]
},
{
"linkId": "3.1.4",
"text": "Felt tired or having little energy",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Several Days"
}
}
]
},
{
"linkId": "3.1.5",
"text": "Had poor appetite or over eating",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "00",
"display": "Not At All"
}
}
]
},
{
"linkId": "3.1.6",
"text": "Felt bad about himself/herself, felt like a failure or he/she has let his/her family down",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Almost everyday"
}
}
]
},
{
"linkId": "3.1.7",
"text": "Trouble concentrating (e.g. watching television or reading newspaper)",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "00",
"display": "Not At All"
}
}
]
},
{
"linkId": "3.1.8",
"text": "Moved slowly or fidgeted excessively that is noticeable by people around him/her",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "00",
"display": "Not At All"
}
}
]
},
{
"linkId": "3.1.9",
"text": "Had thoughts that he/she would be better dead, or hurting yourself",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Several Days"
}
}
]
},
{
"linkId": "3.1.10",
"text": "Total Mental Health Test Score",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "5-9 : Mild Depression"
}
}
]
}
]
},
{
"linkId": "3.2",
"text": "In the last 2 weeks, indicate how difficult these problems made it for this patient",
"item": [
{
"linkId": "3.2.1",
"text": "Do your work, take care of things at home, or get along with others",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Very difficult"
}
}
]
}
]
}
]
},
{
"linkId": "4",
"text": "Lifestyle Health Assessment",
"item": [
{
"linkId": "4.1",
"text": "Alcohol consumption",
"item": [
{
"linkId": "4.1.1",
"text": "How often do you consume alcohol?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "00",
"display": "Never"
}
}
]
},
{
"linkId": "4.1.2",
"text": "How many alcoholic beverages do you consume in a day?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "5-6"
}
}
]
},
{
"linkId": "4.1.3",
"text": "How often within the last year,",
"item": [
{
"linkId": "4.1.3.1",
"text": "Do you consume 6 or more drink in a day?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Once a month"
}
}
]
},
{
"linkId": "4.1.3.2",
"text": "Were you not able to stop drinking once started?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Once a month"
}
}
]
},
{
"linkId": "4.1.3.3",
"text": "Were you not able to perform normal activities due to drinking?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Weekly"
}
}
]
},
{
"linkId": "4.1.3.4",
"text": "You needed to drink first thing in the morning to get going after a heavy drinking session?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Once a month"
}
}
]
},
{
"linkId": "4.1.3.5",
"text": "That you felt guilt or remorse after drinking?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "< Once a month"
}
}
]
},
{
"linkId": "4.1.3.6",
"text": "Were you unable to remember what happened the night before due to drinking?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Once a month"
}
}
]
}
]
},
{
"linkId": "4.1.4",
"text": "Have you or someone else been injured because of your drinking?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Yes, during last year"
}
}
]
},
{
"linkId": "4.1.5",
"text": "Has a relative, friend, doctor, been concerned about your drinking habits?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "00",
"display": "No"
}
}
]
},
{
"linkId": "4.1.6",
"text": "Total Alcohol Consumption Test Score",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "8-12 Moderate Risk"
}
}
]
}
]
},
{
"linkId": "4.2",
"text": "Smoking Status",
"item": [
{
"linkId": "4.2.1",
"text": "Does the patient smoke?",
"answer": [
{
"valueBoolean": true
}
]
},
{
"linkId": "4.2.2",
"text": "Cigarettes per Day",
"answer": [
{
"valueInteger": 1
}
]
},
{
"linkId": "4.2.3",
"text": "Years of Smoking",
"answer": [
{
"valueInteger": 12
}
]
},
{
"linkId": "4.2.4",
"text": "Total pack-years",
"answer": [
{
"valueQuantity": {
"value": 1
}
}
]
}
]
}
]
},
{
"linkId": "5",
"text": "Clinical Parameters",
"item": [
{
"linkId": "5.1",
"text": "Anthropometry: Height",
"answer": [
{
"valueQuantity": {
"value": 168,
"unit": "cm"
}
}
]
},
{
"linkId": "5.2",
"text": "Anthropometry: Weight",
"answer": [
{
"valueQuantity": {
"value": 58,
"unit": "kg"
}
}
]
},
{
"linkId": "5.3",
"text": "Anthropometry: Waistline",
"answer": [
{
"valueQuantity": {
"value": 30,
"unit": "cm"
}
}
]
},
{
"linkId": "5.4",
"text": "BMI calculation",
"answer": [
{
"valueQuantity": {
"value": 30,
"unit": "kg/m2"
}
}
]
},
{
"linkId": "5.5",
"text": "BMI Outcome",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Overweight (25-29.9)"
}
}
]
},
{
"linkId": "5.6",
"text": "Vital Signs: Blood Pressure (systolic)",
"answer": [
{
"valueQuantity": {
"value": 120,
"unit": "mm[Hg]"
}
}
]
},
{
"linkId": "5.7",
"text": "Vital Signs: Blood Pressure (diastolic)",
"answer": [
{
"valueQuantity": {
"value": 90,
"unit": "mm[Hg]"
}
}
]
},
{
"linkId": "5.8",
"text": "Vital Signs: Pulse Rate",
"answer": [
{
"valueQuantity": {
"value": 80,
"unit": "/min"
}
}
]
},
{
"linkId": "5.9",
"text": "Blood Pressure Outcome",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Normal (Systolic <130,Diastolic <85)"
}
}
]
},
{
"linkId": "5.10",
"text": "Point of Care Testing: Blood Glucose",
"item": [
{
"linkId": "5.10.1",
"text": "Fasting",
"answer": [
{
"valueQuantity": {
"value": 12,
"unit": "mmol/L"
}
}
]
},
{
"linkId": "5.10.2",
"text": "Random",
"answer": [
{
"valueQuantity": {
"value": 12,
"unit": "mmol/L"
}
}
]
},
{
"linkId": "5.10.3",
"text": "Blood Glucose Outcome",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Normal Fasting (<5.6)"
}
}
]
}
]
},
{
"linkId": "5.11",
"text": "Point of Care Testing: Blood Cholesterol",
"item": [
{
"linkId": "5.11.1",
"text": "Fasting",
"answer": [
{
"valueQuantity": {
"value": 12,
"unit": "mmol/L"
}
}
]
},
{
"linkId": "5.11.2",
"text": "Random",
"answer": [
{
"valueQuantity": {
"value": 12,
"unit": "mmol/L"
}
}
]
},
{
"linkId": "5.11.3",
"text": "Blood Cholesterol Outcome",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "High >= 5.2 mmol/L"
}
}
]
}
]
}
]
},
{
"linkId": "6",
"text": "Advanced Health Screening (Optional)",
"item": [
{
"linkId": "6.1",
"text": "Cardiovascular",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Ankle Swelling"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Shortness of breath"
}
}
]
},
{
"linkId": "6.2",
"text": "Gastrointestinal",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Nausea and/or vomiting"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Bowel pattern and any changes"
}
}
]
},
{
"linkId": "6.3",
"text": "Genitourinary",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Dysuria"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "04",
"display": "Nocturia"
}
}
]
},
{
"linkId": "6.4",
"text": "Locomotor",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Change in mobility"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Joint pain"
}
}
]
},
{
"linkId": "6.5",
"text": "Neurological",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Seizures"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Transient loss of function (vision, speech, sight)"
}
}
]
},
{
"linkId": "6.6",
"text": "ENT Symptoms",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Snoring"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Epistaxis"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "04",
"display": "Otalgia"
}
}
]
},
{
"linkId": "6.7",
"text": "Dermatology",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Skin color changes"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Rashes"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Ulcers"
}
}
]
}
]
},
{
"linkId": "7",
"text": "Advanced Systemic Examination (Optional)",
"item": [
{
"linkId": "7430591698512",
"text": "General Appearance",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Abnormal"
},
"item": [
{
"linkId": "9491690640065",
"text": "If Abnormal:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Cyanosed"
}
}
]
}
]
}
]
},
{
"linkId": "9385492769029",
"text": "Hands and Arms",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Abnormal"
},
"item": [
{
"linkId": "2706469979386",
"text": "If Abnormal:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "05",
"display": "Dupuytren’s contracture"
}
}
]
}
]
}
]
},
{
"linkId": "803255584502",
"text": "Head",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Abnormal"
},
"item": [
{
"linkId": "2706057387357",
"text": "If Abnormal:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Psoriatic plaque"
}
}
]
}
]
}
]
},
{
"linkId": "5438686906842",
"text": "Neck",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Abnormal"
},
"item": [
{
"linkId": "8525967233111",
"text": "If Abnormal:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Trachea Deviation"
}
}
]
}
]
}
]
},
{
"linkId": "6320853137177",
"text": "Face",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Abnormal"
},
"item": [
{
"linkId": "3567829538338",
"text": "If Abnormal:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "06",
"display": "Increase of facial hair"
}
}
]
}
]
}
]
},
{
"linkId": "2775452197874",
"text": "Mouth",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "00",
"display": "Normal"
},
"item": [
{
"linkId": "2293927557638",
"text": "If Abnormal, Lips:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Stomatitis"
}
}
]
},
{
"linkId": "4080959756844",
"text": "If Abnormal, Gums:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Gingvitis"
}
}
]
},
{
"linkId": "9937565309207",
"text": "If Abnormal, Tongue:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "04",
"display": "Leukplakia"
}
}
]
}
]
}
]
},
{
"linkId": "681882410657",
"text": "Ears, Nose, Throat",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Abnormal"
},
"item": [
{
"linkId": "1009194092473",
"text": "If Abnormal, Ears:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Bleeding"
}
}
]
},
{
"linkId": "5071830545688",
"text": "If Abnormal, Nose:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Epistaxis"
}
}
]
},
{
"linkId": "1032584307566",
"text": "If Abnormal, Throat:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Deviated uvula"
}
}
]
}
]
}
]
},
{
"linkId": "1760871504781",
"text": "Eyes",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Abnormal"
},
"item": [
{
"linkId": "2830264276824",
"text": "If Abnormal, General:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Squint"
}
}
]
},
{
"linkId": "9200420167241",
"text": "If Abnormal, Conjunctiva:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Pallor"
}
}
]
},
{
"linkId": "3896132461914",
"text": "If Abnormal, Cornea:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Kaiser Fleischer's ring (Wilson Disease)"
}
}
]
}
]
}
]
},
{
"linkId": "4541398644599",
"text": "Fundoscopy",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "00",
"display": "Normal"
},
"item": [
{
"linkId": "4508425091768",
"text": "If Abnormal, General:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Others"
}
}
]
},
{
"linkId": "3275429148998",
"text": "If Abnormal, Optic Disc",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Swollen"
}
}
]
},
{
"linkId": "87716190119",
"text": "If Abnormal, Retina:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Arteriovenous nicking"
}
}
]
},
{
"linkId": "1106310017866",
"text": "If Abnormal, Macula:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Exudates"
}
}
]
}
]
}
]
},
{
"linkId": "7802596122190",
"text": "Ishihara Chart:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Abnormal"
}
}
]
},
{
"linkId": "1772552914755",
"text": "Snellen Eye Chart Score",
"item": [
{
"linkId": "5634044053426",
"text": "Snellen Eye Chart Right eye With Lens",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "6/60"
}
}
]
},
{
"linkId": "6868904614360",
"text": "Snellen Eye Chart Right eye Without Lens",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "6/36"
}
}
]
},
{
"linkId": "9535262095025",
"text": "Snellen Eye Chart Left eye With Lens",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "6/36"
}
}
]
},
{
"linkId": "3784286555747",
"text": "Snellen Eye Chart Left eye Without Lens",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "6/36"
}
}
]
}
]
},
{
"linkId": "4357973483106",
"text": "Cardiorespiratory Examination",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Abnormal"
},
"item": [
{
"linkId": "3684125820499",
"text": "Cardiorespiratory Examination, inspection:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Peripheral edema"
}
}
]
},
{
"linkId": "1021145880907",
"text": "Cardiorespiratory Examination, palpation:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Tracheal Deviation"
}
}
]
},
{
"linkId": "5331561684920",
"text": "Cardiorespiratory Examination, percussion:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Chest dullness"
}
}
]
},
{
"linkId": "9727586284871",
"text": "Cardiorespiratory Examination, auscultation",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Crepitations"
}
}
]
}
]
}
]
},
{
"linkId": "3445180818234",
"text": "Abdominal Examination",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Abnormal"
},
"item": [
{
"linkId": "1295584939146",
"text": "Abdominal Examination, inspection:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "Prominent viens"
}
}
]
},
{
"linkId": "6163894014798",
"text": "Abdominal Examination, palpation",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Mass"
}
}
]
},
{
"linkId": "450925187844",
"text": "Abdominal Examination, percussion:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Shufting dullness"
}
}
]
},
{
"linkId": "9695659964510",
"text": "Abdominal Examination, auscultation:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Bruits"
},
"item": [
{
"linkId": "3097284117717",
"text": "Bowel Sound",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Absence"
}
}
]
}
]
}
]
},
{
"linkId": "896081526011",
"text": "Abdominal Examination, other",
"answer": [
{
"valueString": "free text"
}
]
}
]
}
]
},
{
"linkId": "8660013226797",
"text": "Breast Examination",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Abnormal"
},
"item": [
{
"linkId": "2152650190448",
"text": "Breast Examination, inspection:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Scars"
}
}
]
},
{
"linkId": "5834188726294",
"text": "Breast Examination, palpation",
"item": [
{
"linkId": "7571418373717",
"text": "Lump",
"answer": [
{
"valueBoolean": true,
"item": [
{
"linkId": "8412518064517",
"text": "To state position, size, shape, consistency, overlying skin changes and mobility",
"answer": [
{
"valueString": "free text"
}
]
}
]
}
]
},
{
"linkId": "7708835727325",
"text": "Breast Examination, tenderness",
"answer": [
{
"valueBoolean": true
}
]
}
]
},
{
"linkId": "7928508760431",
"text": "Breast Examination, lymph node",
"answer": [
{
"valueBoolean": true,
"item": [
{
"linkId": "5584007098886",
"text": "If yes, state location",
"answer": [
{
"valueString": "free text"
}
]
}
]
}
]
},
{
"linkId": "7966899757129",
"text": "Breast Examination, other",
"answer": [
{
"valueString": "free text"
}
]
}
]
}
]
},
{
"linkId": "4960397935179",
"text": "Genital Examination",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "00",
"display": "Normal"
},
"item": [
{
"linkId": "129761420416",
"text": "If Abnormal:",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Skin lesion"
}
}
]
}
]
}
]
},
{
"linkId": "6294648899702",
"text": "Musculoskeletal Examination",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Abnormal"
},
"item": [
{
"linkId": "6506163486097",
"text": "If Abnormal:",
"answer": [
{
"valueCoding": {
"code": "01",
"display": "Muscle wasting"
}
}
]
}
]
}
]
},
{
"linkId": "8529069579767",
"text": "Neurological Examination",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "00",
"display": "Normal"
},
"item": [
{
"linkId": "2933999220096",
"text": "Neurological Examination, motor",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Right Upper Limb"
},
"item": [
{
"linkId": "5139376034252",
"text": "Neurological Examination, muscle tone",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Hypotonia"
}
}
]
},
{
"linkId": "2810983082307",
"text": "Neurological Examination, muscle power",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "1"
}
}
]
}
]
}
]
},
{
"linkId": "9525382653281",
"text": "Neurological Examination, reflexes",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Left Upper Limb"
},
"item": [
{
"linkId": "1871500398585",
"text": "Neurological Examination, hyperreflex/hyporeflex",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Hyperreflex"
}
}
]
}
]
}
]
},
{
"linkId": "3739755767869",
"text": "Neurological Examination, babinski",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Absent"
}
}
]
},
{
"linkId": "208277417057",
"text": "Neurological Examination, sensation",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Loss of pain sensation"
}
}
]
},
{
"linkId": "969352104031",
"text": "Neurological Examination, other",
"answer": [
{
"valueString": "asd"
}
]
}
]
}
]
}
]
},
{
"linkId": "8",
"text": "Further Investigations",
"item": [
{
"linkId": "8.1",
"text": "Urine dipstick",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "8.2",
"text": "Urine FEME",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "8.3",
"text": "ECG",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "8.4",
"text": "Haemoglobin",
"answer": [
{
"valueString": "123"
}
]
}
]
},
{
"linkId": "9",
"text": "Diagnosis",
"item": [
{
"linkId": "9.1",
"text": "Normal Healthy individual?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "At risk"
}
}
]
},
{
"linkId": "9.2",
"text": "Diagnosis",
"item": [
{
"linkId": "9.2.1",
"text": "Display",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "9.2.2",
"text": "Code",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "9.2.3",
"text": "Code System",
"answer": [
{
"valueString": "123"
}
]
}
]
},
{
"linkId": "9.3",
"text": "Provisional diagnosis",
"item": [
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"linkId": "9.3.1",
"text": "Display",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "9.3.2",
"text": "Code",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "9.3.3",
"text": "Code System",
"answer": [
{
"valueString": "123"
}
]
}
]
}
]
},
{
"linkId": "10",
"text": "Management",
"item": [
{
"linkId": "10.1",
"text": "General management",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "Smoking cessation"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "Dietary advice"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "04",
"display": "Physical activity advice"
}
}
]
},
{
"linkId": "10.2",
"text": "Doctor’s notes",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "10.3",
"text": "Prescription",
"item": [
{
"linkId": "10.3.1",
"text": "Any medication prescribed?",
"answer": [
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "03",
"display": "T. FELODIPINE 5MG"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "02",
"display": "T. AMLODIPINE 10MG"
}
},
{
"valueCoding": {
"system": "http://fhir.hie.moh.gov.my/CodeSystem/nhsi-my-core",
"code": "01",
"display": "T. AMLODIPINE 5MG"
}
}
]
}
]
}
]
},
{
"linkId": "11",
"text": "Verified by",
"item": [
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"linkId": "11.1",
"text": "Officer incharge",
"answer": [
{
"valueString": "123"
}
]
},
{
"linkId": "11.2",
"text": "Registration Number/ IC number",
"answer": [
{
"valueString": "123"
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]
}
]
}
]
}