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Packagesynapxe.sgcdi
Resource TypeBundle
IdBundleSummaryNotesRequest.Example.json
FHIR VersionR5

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Source1

{
  "resourceType": "Bundle",
  "type": "transaction",
  "entry": [
    {
      "fullUrl": "urn:uuid:summarynotes-composition-001",
      "resource": {
        "resourceType": "Composition",
        "id": "summarynotes-001",
        "meta": {
          "profile": [
            "https://fhir.synapxe.sg/StructureDefinition/profile-composition"
          ]
        },
        "identifier": [
          {
            "system": "https://fhir.synapxe.sg/NamingSystem/record-id",
            "value": "SN-REC-2026-00789"
          },
          {
            "system": "https://fhir.synapxe.sg/NamingSystem/accession-no",
            "value": "SN-ACC-2026-00789"
          }
        ],
        "status": "final",
        "type": {
          "extension": [
            {
              "url": "https://fhir.synapxe.sg/StructureDefinition/ext-version",
              "valueString": "1.0"
            }
          ],
          "coding": [
            {
              "system": "https://fhir.synapxe.sg/CodeSystem/nehr-doc-types",
              "code": "SN",
              "display": "Summary Notes"
            }
          ]
        },
        "subject": {
          "type": "Patient",
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/nric",
            "value": "S8765432A"
          }
        },
        "encounter": {
          "type": "Encounter",
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/event-id",
            "value": "SN-ENC-2026-00789"
          }
        },
        "date": "2026-02-09T16:00:00+08:00",
        "author": [
          {
            "reference": "urn:uuid:practitionerrole-001"
          }
        ],
        "title": "Surgical Summary Notes - Laparoscopic Cholecystectomy",
        "custodian": {
          "type": "Organization",
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/hci-code",
            "value": "HCI-54321"
          },
          "display": "National University Hospital"
        },
        "attester": [
          {
            "mode": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/CodeSystem/composition-attestation-mode",
                  "code": "official",
                  "display": "Official"
                }
              ]
            },
            "time": "2026-02-09T16:00:00+08:00",
            "party": {
              "type": "Practitioner",
              "identifier": {
                "system": "https://fhir.synapxe.sg/NamingSystem/mcr",
                "value": "M55555"
              },
              "display": "Dr. Jennifer Lim"
            }
          }
        ],
        "note": [
          {
            "text": "Patient underwent successful laparoscopic cholecystectomy. Recovery was uneventful."
          }
        ],
        "event": [
          {
            "detail": [
              {
                "reference": {
                  "reference": "urn:uuid:sn-procedure-001"
                }
              }
            ]
          }
        ],
        "section": [
          {
            "code": {
              "coding": [
                {
                  "system": "https://fhir.synapxe.sg/CodeSystem/doc-section-type",
                  "code": "questionnaire",
                  "display": "Questionnaire"
                }
              ]
            },
            "entry": [
              {
                "reference": "urn:uuid:sn-questionnaireresponse-001"
              }
            ]
          },
          {
            "code": {
              "coding": [
                {
                  "system": "https://fhir.synapxe.sg/CodeSystem/doc-section-type",
                  "code": "report",
                  "display": "Diagnostic Report"
                }
              ]
            },
            "entry": [
              {
                "reference": "urn:uuid:diagnosticreport-001"
              }
            ]
          },
          {
            "code": {
              "coding": [
                {
                  "system": "https://fhir.synapxe.sg/CodeSystem/doc-section-type",
                  "code": "observation",
                  "display": "Observation"
                }
              ]
            },
            "entry": [
              {
                "reference": "urn:uuid:sn-observation-001"
              }
            ]
          },
          {
            "code": {
              "coding": [
                {
                  "system": "https://fhir.synapxe.sg/CodeSystem/doc-section-type",
                  "code": "condition",
                  "display": "Condition"
                }
              ]
            },
            "entry": [
              {
                "reference": "urn:uuid:sn-condition-001"
              }
            ]
          },
          {
            "code": {
              "coding": [
                {
                  "system": "https://fhir.synapxe.sg/CodeSystem/doc-section-type",
                  "code": "referralRequest",
                  "display": "Referral Request"
                }
              ]
            },
            "entry": [
              {
                "reference": "urn:uuid:sn-referralrequest-001"
              }
            ]
          },
          {
            "code": {
              "coding": [
                {
                  "system": "https://fhir.synapxe.sg/CodeSystem/doc-section-type",
                  "code": "fileAttachment",
                  "display": "File Attachments"
                }
              ]
            },
            "entry": [
              {
                "reference": "urn:uuid:fileattachment-001"
              }
            ]
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Composition"
      }
    },
    {
      "fullUrl": "urn:uuid:practitionerrole-001",
      "resource": {
        "resourceType": "PractitionerRole",
        "id": "practitionerrole-001",
        "meta": {
          "profile": [
            "https://fhir.synapxe.sg/StructureDefinition/profile-practitionerrole"
          ]
        },
        "practitioner": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/mcr",
            "value": "M55555"
          },
          "display": "Dr. Jennifer Lim"
        },
        "organization": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/hci-code",
            "value": "HCI-54321"
          },
          "display": "National University Hospital"
        },
        "code": [
          {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "304292004",
                "display": "Surgeon"
              }
            ]
          }
        ],
        "specialty": [
          {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "394609007",
                "display": "General surgery"
              }
            ]
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "PractitionerRole"
      }
    },
    {
      "fullUrl": "urn:uuid:sn-procedure-001",
      "resource": {
        "resourceType": "Procedure",
        "id": "sn-procedure-001",
        "meta": {
          "profile": [
            "https://fhir.synapxe.sg/StructureDefinition/profile-sn-procedure"
          ]
        },
        "identifier": [
          {
            "system": "https://fhir.synapxe.sg/NamingSystem/procedure-id",
            "value": "PROC-SN-2026-00789"
          }
        ],
        "status": "completed",
        "code": {
          "coding": [
            {
              "system": "http://snomed.info/sct",
              "code": "45595009",
              "display": "Laparoscopic cholecystectomy"
            }
          ],
          "text": "Laparoscopic cholecystectomy with intraoperative cholangiography"
        },
        "subject": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/nric",
            "value": "S8765432A"
          }
        },
        "encounter": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/event-id",
            "value": "SN-ENC-2026-00789"
          }
        },
        "occurrencePeriod": {
          "start": "2026-02-09T09:00:00+08:00",
          "end": "2026-02-09T11:30:00+08:00"
        },
        "recorded": "2026-02-09T11:30:00+08:00",
        "performer": [
          {
            "function": {
              "coding": [
                {
                  "system": "http://snomed.info/sct",
                  "code": "304292004",
                  "display": "Surgeon"
                }
              ]
            },
            "actor": {
              "identifier": {
                "system": "https://fhir.synapxe.sg/NamingSystem/mcr",
                "value": "M55555"
              },
              "display": "Dr. Jennifer Lim"
            }
          }
        ],
        "reason": [
          {
            "concept": {
              "coding": [
                {
                  "system": "http://snomed.info/sct",
                  "code": "235919008",
                  "display": "Acute cholecystitis"
                }
              ]
            }
          }
        ],
        "bodySite": [
          {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "28231008",
                "display": "Gallbladder structure"
              }
            ]
          }
        ],
        "outcome": {
          "coding": [
            {
              "system": "http://snomed.info/sct",
              "code": "385669000",
              "display": "Successful"
            }
          ],
          "text": "Procedure completed successfully without complications"
        },
        "report": [
          {
            "reference": "urn:uuid:diagnosticreport-001"
          }
        ],
        "complication": [],
        "followUp": [
          {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "183624006",
                "display": "Follow-up 2 weeks"
              }
            ]
          }
        ],
        "note": [
          {
            "text": "Gallbladder removed intact. No bile spillage. Hemostasis achieved. All ports closed appropriately."
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Procedure"
      }
    },
    {
      "fullUrl": "urn:uuid:sn-questionnaireresponse-001",
      "resource": {
        "resourceType": "QuestionnaireResponse",
        "id": "sn-questionnaireresponse-001",
        "meta": {
          "profile": [
            "https://fhir.synapxe.sg/StructureDefinition/profile-sn-questionnaireresponse"
          ]
        },
        "questionnaire": "https://fhir.synapxe.sg/Questionnaire/surgical-assessment",
        "status": "completed",
        "subject": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/nric",
            "value": "S8765432A"
          }
        },
        "encounter": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/event-id",
            "value": "SN-ENC-2026-00789"
          }
        },
        "authored": "2026-02-09T08:00:00+08:00",
        "author": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/mcr",
            "value": "M55555"
          },
          "display": "Dr. Jennifer Lim"
        },
        "item": [
          {
            "linkId": "1",
            "text": "Pre-operative Assessment",
            "item": [
              {
                "linkId": "1.1",
                "text": "ASA Classification",
                "answer": [
                  {
                    "valueCoding": {
                      "system": "http://snomed.info/sct",
                      "code": "413107003",
                      "display": "ASA II - Patient with mild systemic disease"
                    }
                  }
                ]
              },
              {
                "linkId": "1.2",
                "text": "Fasting Status",
                "answer": [
                  {
                    "valueString": "NPO since midnight, 8 hours fasting"
                  }
                ]
              }
            ]
          },
          {
            "linkId": "2",
            "text": "Intraoperative Findings",
            "item": [
              {
                "linkId": "2.1",
                "text": "Gallbladder condition",
                "answer": [
                  {
                    "valueString": "Inflamed gallbladder with multiple small stones. No perforation."
                  }
                ]
              },
              {
                "linkId": "2.2",
                "text": "Any complications during surgery",
                "answer": [
                  {
                    "valueBoolean": false
                  }
                ]
              }
            ]
          },
          {
            "linkId": "3",
            "text": "Post-operative Plan",
            "item": [
              {
                "linkId": "3.1",
                "text": "Discharge plan",
                "answer": [
                  {
                    "valueString": "Discharge on day 2 post-op if stable"
                  }
                ]
              }
            ]
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "QuestionnaireResponse"
      }
    },
    {
      "fullUrl": "urn:uuid:diagnosticreport-001",
      "resource": {
        "resourceType": "DiagnosticReport",
        "id": "diagnosticreport-001",
        "meta": {
          "profile": [
            "https://fhir.synapxe.sg/StructureDefinition/profile-diagnosticreport"
          ]
        },
        "status": "final",
        "category": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
                "code": "SP",
                "display": "Surgical Pathology"
              }
            ]
          }
        ],
        "code": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "60567-5",
              "display": "Comprehensive surgical pathology report"
            }
          ],
          "text": "Histopathology Report - Gallbladder"
        },
        "subject": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/nric",
            "value": "S8765432A"
          }
        },
        "encounter": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/event-id",
            "value": "SN-ENC-2026-00789"
          }
        },
        "effectiveDateTime": "2026-02-09T11:30:00+08:00",
        "issued": "2026-02-11T14:00:00+08:00",
        "performer": [
          {
            "identifier": {
              "system": "https://fhir.synapxe.sg/NamingSystem/hci-code",
              "value": "HCI-54321"
            },
            "display": "National University Hospital - Pathology Department"
          }
        ],
        "result": [
          {
            "reference": "urn:uuid:sn-observation-001"
          }
        ],
        "conclusion": "Chronic cholecystitis with cholelithiasis. Multiple pigmented gallstones. No evidence of dysplasia or malignancy."
      },
      "request": {
        "method": "POST",
        "url": "DiagnosticReport"
      }
    },
    {
      "fullUrl": "urn:uuid:sn-observation-001",
      "resource": {
        "resourceType": "Observation",
        "id": "sn-observation-001",
        "meta": {
          "profile": [
            "https://fhir.synapxe.sg/StructureDefinition/profile-sn-observation"
          ]
        },
        "status": "final",
        "category": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/observation-category",
                "code": "laboratory",
                "display": "Laboratory"
              }
            ]
          }
        ],
        "code": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "22637-3",
              "display": "Pathology report final diagnosis"
            }
          ],
          "text": "Histopathology findings"
        },
        "subject": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/nric",
            "value": "S8765432A"
          }
        },
        "encounter": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/event-id",
            "value": "SN-ENC-2026-00789"
          }
        },
        "effectiveDateTime": "2026-02-11T14:00:00+08:00",
        "issued": "2026-02-11T14:00:00+08:00",
        "performer": [
          {
            "identifier": {
              "system": "https://fhir.synapxe.sg/NamingSystem/mcr",
              "value": "M77777"
            },
            "display": "Dr. Ahmad Pathologist"
          }
        ],
        "valueString": "Gallbladder wall shows chronic inflammatory changes. Multiple pigmented stones identified. No evidence of dysplasia or malignancy.",
        "note": [
          {
            "text": "Specimen: Gallbladder, entire. Gross description: Received fresh a 9cm gallbladder. Wall thickness ranges 0.2-0.5cm. Contains multiple black pigmented stones."
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Observation"
      }
    },
    {
      "fullUrl": "urn:uuid:sn-condition-001",
      "resource": {
        "resourceType": "Condition",
        "id": "sn-condition-001",
        "meta": {
          "profile": [
            "https://fhir.synapxe.sg/StructureDefinition/profile-sn-condition"
          ]
        },
        "clinicalStatus": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
              "code": "resolved",
              "display": "Resolved"
            }
          ]
        },
        "verificationStatus": {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
              "code": "confirmed",
              "display": "Confirmed"
            }
          ]
        },
        "category": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/condition-category",
                "code": "encounter-diagnosis",
                "display": "Encounter Diagnosis"
              }
            ]
          }
        ],
        "severity": {
          "coding": [
            {
              "system": "http://snomed.info/sct",
              "code": "24484000",
              "display": "Severe"
            }
          ]
        },
        "code": {
          "coding": [
            {
              "system": "http://snomed.info/sct",
              "code": "235919008",
              "display": "Acute cholecystitis"
            }
          ],
          "text": "Acute cholecystitis with cholelithiasis"
        },
        "bodySite": [
          {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "28231008",
                "display": "Gallbladder structure"
              }
            ]
          }
        ],
        "subject": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/nric",
            "value": "S8765432A"
          }
        },
        "encounter": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/event-id",
            "value": "SN-ENC-2026-00789"
          }
        },
        "onsetDateTime": "2026-02-05T00:00:00+08:00",
        "abatementDateTime": "2026-02-09T11:30:00+08:00",
        "recordedDate": "2026-02-09T16:00:00+08:00",
        "note": [
          {
            "text": "Patient presented with right upper quadrant pain, fever, and positive Murphy's sign. Ultrasound confirmed acute cholecystitis. Condition resolved following surgical removal of gallbladder."
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Condition"
      }
    },
    {
      "fullUrl": "urn:uuid:sn-referralrequest-001",
      "resource": {
        "resourceType": "ServiceRequest",
        "id": "sn-referralrequest-001",
        "meta": {
          "profile": [
            "https://fhir.synapxe.sg/StructureDefinition/profile-sn-referralrequest"
          ]
        },
        "status": "active",
        "intent": "order",
        "category": [
          {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "3457005",
                "display": "Referral"
              }
            ]
          }
        ],
        "priority": "routine",
        "code": {
          "coding": [
            {
              "system": "http://snomed.info/sct",
              "code": "183561000",
              "display": "Referral to gastroenterologist"
            }
          ],
          "text": "Post-operative follow-up with gastroenterology"
        },
        "subject": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/nric",
            "value": "S8765432A"
          }
        },
        "encounter": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/event-id",
            "value": "SN-ENC-2026-00789"
          }
        },
        "occurrenceDateTime": "2026-02-23T00:00:00+08:00",
        "authoredOn": "2026-02-09T16:00:00+08:00",
        "requester": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/mcr",
            "value": "M55555"
          },
          "display": "Dr. Jennifer Lim"
        },
        "performer": [
          {
            "identifier": {
              "system": "https://fhir.synapxe.sg/NamingSystem/hci-code",
              "value": "HCI-54321-GASTRO"
            },
            "display": "NUH Gastroenterology Clinic"
          }
        ],
        "reasonCode": [
          {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "302497006",
                "display": "Post-operative disorder of digestive system"
              }
            ],
            "text": "Follow-up for post-cholecystectomy syndrome monitoring"
          }
        ],
        "note": [
          {
            "text": "Patient to be reviewed in 2 weeks for assessment of post-operative bile duct function and to rule out post-cholecystectomy syndrome."
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "ServiceRequest"
      }
    },
    {
      "fullUrl": "urn:uuid:fileattachment-001",
      "resource": {
        "resourceType": "DocumentReference",
        "id": "fileattachment-001",
        "meta": {
          "profile": [
            "https://fhir.synapxe.sg/StructureDefinition/profile-fileattachment"
          ]
        },
        "status": "current",
        "type": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "18748-4",
              "display": "Diagnostic imaging study"
            }
          ],
          "text": "Intraoperative cholangiogram images"
        },
        "category": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/document-classcode",
                "code": "image",
                "display": "Image"
              }
            ]
          }
        ],
        "subject": {
          "identifier": {
            "system": "https://fhir.synapxe.sg/NamingSystem/nric",
            "value": "S8765432A"
          }
        },
        "context": [
          {
            "reference": {
              "identifier": {
                "system": "https://fhir.synapxe.sg/NamingSystem/event-id",
                "value": "SN-ENC-2026-00789"
              }
            }
          }
        ],
        "content": [
          {
            "attachment": {
              "contentType": "image/dicom",
              "url": "https://pacs.nuh.sg/studies/SN-2026-00789-cholangiogram",
              "title": "Intraoperative Cholangiogram",
              "creation": "2026-02-09T10:15:00+08:00",
              "size": 1524288
            }
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "DocumentReference"
      }
    }
  ]
}