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 :
- Informasi Organization yang disimpan pada Sistem Informasi Fasyankes berupa Organisasi induk (
Organization IHS Number& nama fasyankes), dan identitas Sub Organisasi (Organization.id & nama suborganisasi). - Informasi Location poliklinik yang disimpan pada Sistem Informasi Fasyankes berupa
Location.iddan identitas nama poliklinik. - Identitas Practitioner yang disimpan pada Sistem Informasi Fasyankes berupa
Practitioner IHS Numberdan identitas nama dokter. - 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:
- Primer: Penyakit Tuberkulosis Paru berdasarkan hasil tes sputum dan diabetes melitus tipe 2
- Sekunder: Diabetes Mellitus tanpa komplikasi
Resource used : Encounter, Condition
1. Pendaftaran Kunjungan Pasien Walk-in
| Method | POST |
| Target URL | |
{
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| 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 |
| id : Example-Encounter-Registration-Payload |
| identifier |
| system : http://sys-ids.kemkes.go.id/encounter/10000004 |
| value : P20240001 |
| status : arrived |
| statusHistory |
| status : arrived |
| period |
| start : 2022-06-14T07:00:00+07:00 |
| end : 2022-06-14T08:00:00+07:00 |
| 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 |
| serviceProvider |
| reference : Organization/10000004 |
| 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 |
{
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2. Transisi Status Pelayanan Pasien menjadi dilayani
| Method | PUT |
| Target URL |
|
{
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| 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 |
| id : 2823ed1d-3e3e-434e-9a5b-9c579d192787 |
| identifier |
| system : http://sys-ids.kemkes.go.id/encounter/1000004 |
| value : P20240001 |
| status : in-progress |
| statusHistory |
| status : arrived |
| period |
| start : 2022-06-14T07:00:00+07:00 |
| end : 2022-06-14T08:00:00+07:00 |
| statusHistory |
| status : in-progress |
| period |
| start : 2022-06-14T08:00:00+07:00 |
| end : 2022-06-14T09:00:00+07:00 |
| 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 |
| serviceProvider |
| reference : Organization/10000004 |
| 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 |
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}
3. Melakukan Pengiriman Diagnosa Primer
| Method | POST |
| Target URL | |
{
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| 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 |
| 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 |
| onset : 2022-07-29 |
| recordedDate : 2022-07-29 |
| 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 |
{
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4. Melakukan Pengiriman Diagnosa Secondary
| Method | POST |
| Target URL | |
{
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{
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| 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 |
| 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 |
| onset : 2022-06-14 |
| recordedDate : 2022-06-14 |
| 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 |
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