Medical Resume Part 1 -- Kunjungan dan Diagnosis



Pada Medical Resume Part 1, akan dijelaskan bagaimana cara mengisi kunjungan dan diagnosis pasien. Kunjungan dan diagnosis merupakan data yang sangat penting untuk mengetahui kondisi pasien. Data ini merupakan data esensial yang didapatkan pada fasilitas kesehatan dasar dimulai dari praktik mandiri, klinik, puskesmas, dan rumah sakit. Informasi ini digunakan untuk menentukan tindakan selanjutnya yang akan dilakukan oleh dokter dan menentukan obat yang akan diberikan kepada pasien.

Sebelum memulai mengisi kunjungan dan diagnosis, pastikan bahwa Sistem Informasi sudah memiliki data prasyarat sebagai berikut :

  1. Informasi Organization yang disimpan pada Sistem Informasi Fasyankes berupa Organisasi induk (Organization IHS Number & nama fasyankes), dan identitas Sub Organisasi (Organization.id & nama suborganisasi).
  2. Informasi Location poliklinik yang disimpan pada Sistem Informasi Fasyankes berupa Location.id dan identitas nama poliklinik.
  3. Identitas Practitioner yang disimpan pada Sistem Informasi Fasyankes berupa Practitioner IHS Number dan identitas nama dokter.
  4. Identitas Patient yang disimpan pada Sistem Informasi Fasyankes berupa Patient IHS Number.



Ilustrasi Kasus Resume Medis Part 1

Pasien bernama Budi Santoso melakukan kunjungan rawat jalan dengan Dokter Bronsig pada tanggal 14 Juni 2022 jam 7 pagi di RSUD Jati Asih. Budi selesai diperiksa oleh dokter dan didiagnosa dengan:

  1. Primer: Penyakit Tuberkulosis Paru berdasarkan hasil tes sputum dan diabetes melitus tipe 2
  2. Sekunder: Diabetes Mellitus tanpa komplikasi

Resource used : Encounter, Condition

1. Pendaftaran Kunjungan Pasien Walk-in

Method POST
Target URL 
{{base_url}}/Encounter
 

{
    "resourceType": "Encounter",
    "id": "Example-Encounter-Registration-Payload",
    "identifier":  [
        {
            "system": "http://sys-ids.kemkes.go.id/encounter/10000004",
            "value": "P20240001"
        }
    ],
    "status": "arrived",
    "class": {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code": "AMB",
        "display": "ambulatory"
    },
    "subject": {
        "reference": "Patient/100000030009",
        "display": "Budi Santoso"
    },
    "participant":  [
        {
            "type":  [
                {
                    "coding":  [
                        {
                            "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                            "code": "ATND",
                            "display": "attender"
                        }
                    ]
                }
            ],
            "individual": {
                "reference": "Practitioner/N10000001",
                "display": "Dokter Bronsig"
            }
        }
    ],
    "period": {
        "start": "2022-06-14T07:00:00+07:00"
    },
    "location":  [
        {
            "location": {
                "reference": "Location/ef011065-38c9-46f8-9c35-d1fe68966a3e",
                "display": "Ruang 1A, Poliklinik Rawat Jalan"
            }
        }
    ],
    "statusHistory":  [
        {
            "status": "arrived",
            "period": {
                "start": "2022-06-14T07:00:00+07:00",
                "end": "2022-06-14T08:00:00+07:00"
            }
        }
    ],
    "serviceProvider": {
        "reference": "Organization/10000004"
    }
}
Encounter.id[0]Example-Encounter-Registration-Payload
Encounter.identifier[0].system[0]http://sys-ids.kemkes.go.id/encounter/10000004
Encounter.identifier[0].value[0]P20240001
Encounter.status[0]arrived
Encounter.statusHistory[0].status[0]arrived
Encounter.statusHistory[0].period[0].start[0]2022-06-14T07:00:00+07:00
Encounter.statusHistory[0].period[0].end[0]2022-06-14T08:00:00+07:00
Encounter.class[0].system[0]http://terminology.hl7.org/CodeSystem/v3-ActCode
Encounter.class[0].code[0]AMB
Encounter.class[0].display[0]ambulatory
Encounter.subject[0].reference[0]Patient/100000030009
Encounter.subject[0].display[0]Budi Santoso
Encounter.participant[0].type[0].coding[0].system[0]http://terminology.hl7.org/CodeSystem/v3-ParticipationType
Encounter.participant[0].type[0].coding[0].code[0]ATND
Encounter.participant[0].type[0].coding[0].display[0]attender
Encounter.participant[0].individual[0].reference[0]Practitioner/N10000001
Encounter.participant[0].individual[0].display[0]Dokter Bronsig
Encounter.period[0].start[0]2022-06-14T07:00:00+07:00
Encounter.location[0].location[0].reference[0]Location/ef011065-38c9-46f8-9c35-d1fe68966a3e
Encounter.location[0].location[0].display[0]Ruang 1A, Poliklinik Rawat Jalan
Encounter.serviceProvider[0].reference[0]Organization/10000004
Encounter



Response 201 Created
Catatan Didalam response akan ada Encounter.id = 2823ed1d-3e3e-434e-9a5b-9c579d192787 yang di generate secara otomatis. Simpan Encounter.id ini untuk dirujuk oleh resource lain 



{
    "class": {
        "code": "AMB",
        "display": "ambulatory",
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode"
    },
    "id": "2823ed1d-3e3e-434e-9a5b-9c579d192787",
    "identifier":  [
        {
            "system": "http://sys-ids.kemkes.go.id/encounter/10000004",
            "value": "P20240001"
        }
    ],
    "location":  [
        {
            "location": {
                "display": "Ruang 1A, Poliklinik Rawat Jalan",
                "reference": "Location/ef011065-38c9-46f8-9c35-d1fe68966a3e"
            }
        }
    ],
    "meta": {
        "lastUpdated": "2022-08-11T14:35:09.810004+00:00",
        "versionId": "MTY2MDIyODUwOTgxMDAwNDAwMA"
    },
    "participant":  [
        {
            "individual": {
                "display": "Dokter Bronsig",
                "reference": "Practitioner/N10000001"
            },
            "type":  [
                {
                    "coding":  [
                        {
                            "code": "ATND",
                            "display": "attender",
                            "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType"
                        }
                    ]
                }
            ]
        }
    ],
    "period": {
        "start": "2022-06-14T07:00:00+07:00"
    },
    "resourceType": "Encounter",
    "serviceProvider": {
        "reference": "Organization/10000004"
    },
    "status": "arrived",
    "statusHistory":  [
        {
            "period": {
                "end": "2022-06-14T08:00:00+07:00",
                "start": "2022-06-14T07:00:00+07:00"
            },
            "status": "arrived"
        }
    ],
    "subject": {
        "display": "Budi Santoso",
        "reference": "Patient/100000030009"
    }
}

2. Transisi Status Pelayanan Pasien menjadi dilayani

Method PUT
Target URL 
{{base_url}}/Encounter/2823ed1d-3e3e-434e-9a5b-9c579d192787
 

{
    "resourceType": "Encounter",
    "id": "2823ed1d-3e3e-434e-9a5b-9c579d192787",
    "identifier":  [
        {
            "system": "http://sys-ids.kemkes.go.id/encounter/1000004",
            "value": "P20240001"
        }
    ],
    "status": "in-progress",
    "class": {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
        "code": "AMB",
        "display": "ambulatory"
    },
    "subject": {
        "reference": "Patient/100000030009",
        "display": "Budi Santoso"
    },
    "participant":  [
        {
            "type":  [
                {
                    "coding":  [
                        {
                            "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
                            "code": "ATND",
                            "display": "attender"
                        }
                    ]
                }
            ],
            "individual": {
                "reference": "Practitioner/N10000001",
                "display": "Dokter Bronsig"
            }
        }
    ],
    "period": {
        "start": "2022-06-14T07:00:00+07:00",
        "end": "2022-06-14T09:00:00+07:00"
    },
    "location":  [
        {
            "location": {
                "reference": "Location/ef011065-38c9-46f8-9c35-d1fe68966a3e",
                "display": "Ruang 1A, Poliklinik Rawat Jalan"
            }
        }
    ],
    "statusHistory":  [
        {
            "status": "arrived",
            "period": {
                "start": "2022-06-14T07:00:00+07:00",
                "end": "2022-06-14T08:00:00+07:00"
            }
        },
        {
            "status": "in-progress",
            "period": {
                "start": "2022-06-14T08:00:00+07:00",
                "end": "2022-06-14T09:00:00+07:00"
            }
        }
    ],
    "serviceProvider": {
        "reference": "Organization/10000004"
    }
}
Encounter.id[0]2823ed1d-3e3e-434e-9a5b-9c579d192787
Encounter.identifier[0].system[0]http://sys-ids.kemkes.go.id/encounter/1000004
Encounter.identifier[0].value[0]P20240001
Encounter.status[0]in-progress
Encounter.statusHistory[0].status[0]arrived
Encounter.statusHistory[0].period[0].start[0]2022-06-14T07:00:00+07:00
Encounter.statusHistory[0].period[0].end[0]2022-06-14T08:00:00+07:00
Encounter.statusHistory[1].status[0]in-progress
Encounter.statusHistory[1].period[0].start[0]2022-06-14T08:00:00+07:00
Encounter.statusHistory[1].period[0].end[0]2022-06-14T09:00:00+07:00
Encounter.class[0].system[0]http://terminology.hl7.org/CodeSystem/v3-ActCode
Encounter.class[0].code[0]AMB
Encounter.class[0].display[0]ambulatory
Encounter.subject[0].reference[0]Patient/100000030009
Encounter.subject[0].display[0]Budi Santoso
Encounter.participant[0].type[0].coding[0].system[0]http://terminology.hl7.org/CodeSystem/v3-ParticipationType
Encounter.participant[0].type[0].coding[0].code[0]ATND
Encounter.participant[0].type[0].coding[0].display[0]attender
Encounter.participant[0].individual[0].reference[0]Practitioner/N10000001
Encounter.participant[0].individual[0].display[0]Dokter Bronsig
Encounter.period[0].start[0]2022-06-14T07:00:00+07:00
Encounter.period[0].end[0]2022-06-14T09:00:00+07:00
Encounter.location[0].location[0].reference[0]Location/ef011065-38c9-46f8-9c35-d1fe68966a3e
Encounter.location[0].location[0].display[0]Ruang 1A, Poliklinik Rawat Jalan
Encounter.serviceProvider[0].reference[0]Organization/10000004
Encounter



Response 200 OK
Catatan Encounter.id 2823ed1d-3e3e-434e-9a5b-9c579d192787 yang ada di response harap disimpan untuk dirujuk oleh resource lain atau PUT Encounter 



{
    "class": {
        "code": "AMB",
        "display": "ambulatory",
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode"
    },
    "id": "2823ed1d-3e3e-434e-9a5b-9c579d192787",
    "identifier":  [
        {
            "system": "http://sys-ids.kemkes.go.id/encounter/1000004",
            "value": "P20240001"
        }
    ],
    "location":  [
        {
            "location": {
                "display": "Ruang 1A, Poliklinik Rawat Jalan",
                "reference": "Location/ef011065-38c9-46f8-9c35-d1fe68966a3e"
            }
        }
    ],
    "meta": {
        "lastUpdated": "2022-10-12T01:02:56.964105+00:00",
        "versionId": "MTY2NTUzNjU3Njk2NDEwNTAwMA"
    },
    "participant":  [
        {
            "individual": {
                "display": "Dokter Bronsig",
                "reference": "Practitioner/N10000001"
            },
            "type":  [
                {
                    "coding":  [
                        {
                            "code": "ATND",
                            "display": "attender",
                            "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType"
                        }
                    ]
                }
            ]
        }
    ],
    "period": {
        "end": "2022-06-14T09:00:00+07:00",
        "start": "2022-06-14T07:00:00+07:00"
    },
    "resourceType": "Encounter",
    "serviceProvider": {
        "reference": "Organization/10000004"
    },
    "status": "in-progress",
    "statusHistory":  [
        {
            "period": {
                "end": "2022-06-14T08:00:00+07:00",
                "start": "2022-06-14T07:00:00+07:00"
            },
            "status": "arrived"
        },
        {
            "period": {
                "end": "2022-06-14T09:00:00+07:00",
                "start": "2022-06-14T08:00:00+07:00"
            },
            "status": "in-progress"
        }
    ],
    "subject": {
        "display": "Budi Santoso",
        "reference": "Patient/100000030009"
    }
}

3. Melakukan Pengiriman Diagnosa Primer

Method POST
Target URL 
{{base_url}}/Condition
 

{
    "resourceType": "Condition",
    "id": "Example-Condition-A15.0-Payload",
    "clinicalStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code": "active",
                "display": "Active"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://terminology.hl7.org/CodeSystem/condition-category",
                    "code": "encounter-diagnosis",
                    "display": "Encounter Diagnosis"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://hl7.org/fhir/sid/icd-10",
                "code": "A15.0",
                "display": "Tuberculosis of lung, confirmed by sputum microscopy with or without culture"
            }
        ]
    },
    "subject": {
        "reference": "Patient/100000030009",
        "display": "Budi Santoso"
    },
    "encounter": {
        "reference": "Encounter/14e8398c-1016-44b8-b619-a802b80d2c94"
    },
    "onsetDateTime": "2022-07-29",
    "recordedDate": "2022-07-29"
}
Condition.id[0]Example-Condition-A15.0-Payload
Condition.clinicalStatus[0].coding[0].system[0]http://terminology.hl7.org/CodeSystem/condition-clinical
Condition.clinicalStatus[0].coding[0].code[0]active
Condition.clinicalStatus[0].coding[0].display[0]Active
Condition.category[0].coding[0].system[0]http://terminology.hl7.org/CodeSystem/condition-category
Condition.category[0].coding[0].code[0]encounter-diagnosis
Condition.category[0].coding[0].display[0]Encounter Diagnosis
Condition.code[0].coding[0].system[0]http://hl7.org/fhir/sid/icd-10
Condition.code[0].coding[0].code[0]A15.0
Condition.code[0].coding[0].display[0]Tuberculosis of lung, confirmed by sputum microscopy with or without culture
Condition.subject[0].reference[0]Patient/100000030009
Condition.subject[0].display[0]Budi Santoso
Condition.encounter[0].reference[0]Encounter/14e8398c-1016-44b8-b619-a802b80d2c94
Condition.onset[0]2022-07-29
Condition.recordedDate[0]2022-07-29
Condition



Response 201 Created
Catatan Didalam response akan ada Condition.id = f2bc12fe-0ab2-4e5c-a3cd-32c66150cbe9 yang di generate secara otomatis. Simpan Condition.id ini untuk dirujuk oleh resource Encounter 



{
    "category":  [
        {
            "coding":  [
                {
                    "code": "encounter-diagnosis",
                    "display": "Encounter Diagnosis",
                    "system": "http://terminology.hl7.org/CodeSystem/condition-category"
                }
            ]
        }
    ],
    "clinicalStatus": {
        "coding":  [
            {
                "code": "active",
                "display": "Active",
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical"
            }
        ]
    },
    "code": {
        "coding":  [
            {
                "code": "A15.0",
                "display": "Tuberculosis of lung, confirmed by sputum microscopy with or without culture",
                "system": "http://hl7.org/fhir/sid/icd-10"
            }
        ]
    },
    "encounter": {
        "reference": "Encounter/2823ed1d-3e3e-434e-9a5b-9c579d192787"
    },
    "id": "f2bc12fe-0ab2-4e5c-a3cd-32c66150cbe9",
    "meta": {
        "lastUpdated": "2022-08-11T14:49:25.289752+00:00",
        "versionId": "MTY2MDIyOTM2NTI4OTc1MjAwMA"
    },
    "onsetDateTime": "2022-06-14",
    "recordedDate": "2022-06-14",
    "resourceType": "Condition",
    "subject": {
        "display": "Budi Santoso",
        "reference": "Patient/100000030009"
    }
}

4. Melakukan Pengiriman Diagnosa Secondary

Method POST
Target URL 
{{base_url}}/Condition
 

{
    "resourceType": "Condition",
    "id": "Example-Condition-E11.9-Payload",
    "clinicalStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code": "active",
                "display": "Active"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://terminology.hl7.org/CodeSystem/condition-category",
                    "code": "encounter-diagnosis",
                    "display": "Encounter Diagnosis"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://hl7.org/fhir/sid/icd-10",
                "code": "E11.9",
                "display": "Non-insulin-dependent diabetes mellitus without complications "
            }
        ]
    },
    "subject": {
        "reference": "Patient/100000030009",
        "display": "Budi Santoso"
    },
    "encounter": {
        "reference": "Encounter/2823ed1d-3e3e-434e-9a5b-9c579d192787",
        "display": "Kunjungan Budi Santoso di hari Selasa, 14 Juni 2022"
    },
    "onsetDateTime": "2022-06-14",
    "recordedDate": "2022-06-14"
}
Condition.id[0]Example-Condition-E11.9-Payload
Condition.clinicalStatus[0].coding[0].system[0]http://terminology.hl7.org/CodeSystem/condition-clinical
Condition.clinicalStatus[0].coding[0].code[0]active
Condition.clinicalStatus[0].coding[0].display[0]Active
Condition.category[0].coding[0].system[0]http://terminology.hl7.org/CodeSystem/condition-category
Condition.category[0].coding[0].code[0]encounter-diagnosis
Condition.category[0].coding[0].display[0]Encounter Diagnosis
Condition.code[0].coding[0].system[0]http://hl7.org/fhir/sid/icd-10
Condition.code[0].coding[0].code[0]E11.9
Condition.code[0].coding[0].display[0]Non-insulin-dependent diabetes mellitus without complications
Condition.subject[0].reference[0]Patient/100000030009
Condition.subject[0].display[0]Budi Santoso
Condition.encounter[0].reference[0]Encounter/2823ed1d-3e3e-434e-9a5b-9c579d192787
Condition.encounter[0].display[0]Kunjungan Budi Santoso di hari Selasa, 14 Juni 2022
Condition.onset[0]2022-06-14
Condition.recordedDate[0]2022-06-14
Condition



Response 201 Created
Catatan Didalam response akan ada Condition.id = ba0dd351-c30a-4659-994e-0013797b545b yang di generate secara otomatis. Simpan Condition.id ini untuk dirujuk oleh resource Encounter 



{
    "category":  [
        {
            "coding":  [
                {
                    "code": "encounter-diagnosis",
                    "display": "Encounter Diagnosis",
                    "system": "http://terminology.hl7.org/CodeSystem/condition-category"
                }
            ]
        }
    ],
    "clinicalStatus": {
        "coding":  [
            {
                "code": "active",
                "display": "Active",
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical"
            }
        ]
    },
    "code": {
        "coding":  [
            {
                "code": "E11.9",
                "display": "Non-insulin-dependent diabetes mellitus without complications ",
                "system": "http://hl7.org/fhir/sid/icd-10"
            }
        ]
    },
    "encounter": {
        "display": "Kunjungan Budi Santoso di hari Selasa, 14 Juni 2022",
        "reference": "Encounter/2823ed1d-3e3e-434e-9a5b-9c579d192787"
    },
    "id": "ba0dd351-c30a-4659-994e-0013797b545b",
    "meta": {
        "lastUpdated": "2022-08-11T14:51:14.144921+00:00",
        "versionId": "MTY2MDIyOTQ3NDE0NDkyMTAwMA"
    },
    "onsetDateTime": "2022-06-14",
    "recordedDate": "2022-06-14",
    "resourceType": "Condition",
    "subject": {
        "display": "Budi Santoso",
        "reference": "Patient/100000030009"
    }
}

5. Transisi Status Pelayanan Pasien menjadi Selesai



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