Pengenalan Use-case Resume Medis Rawat Jalan
Introduksi Use-case Resume Medis Rawat Jalan
Resume medis adalah resume yang diberikan oleh dokter kepada pasien yang telah menjalani perawatan di rumah sakit. Resume medis ini berisi informasi tentang kondisi pasien, diagnosis, tindakan medis, dan resep obat yang diberikan kepada pasien. Resume medis ini juga dapat digunakan oleh dokter lain untuk melihat kondisi pasien yang telah pernah dirawat oleh dokter lain. Resume medis ini juga dapat digunakan oleh pasien untuk melihat kondisi dirinya sendiri.
Tahapan alur layanan rawat jalan secara umum dapat dilihat pada Gambar 1 :

Gambar 1. Alur Layanan Rawat Jalan
Peta jalan pengiriman data dari Sistem Informasi Fasilitas Kesehatan terlampir pada Gambar 2 :
Gambar 2. Metode pengiriman Resource FHIR Resume Rawat Jalan
Pada tabel dibawah terlampir adalah FHIR resource yang digunakan untuk resume medis rawat jalan :
No | Variabel | Resource FHIR | Path FHIR | |
1 | Identitas Umum Pasien | |||
a | Nomor SATUSEHAT Pasien | Patient | Patient.identifier.use | |
Patient.identifier.system | ||||
Patient.identifier.value | ||||
b | Nama Lengkap | Patient | Patient.name.text | |
c | Nomor Induk Kependudukan (NIK) | Patient | Patient.identifier.use | |
Patient.identifier.system | ||||
Patient.identifier.value | ||||
d | Nomor Identitas Lain (Khusus WNA) : Nomor Paspor / KITAS | Patient | Patient.identifier.use | |
Patient.identifier.system | ||||
Patient.identifier.value | ||||
e | Tempat Lahir | Patient | Patient.extension:birthPlace | |
f | Tanggal Lahir | Patient | Patient.birthDate | |
g | Jenis Kelamin | Patient | Patient.gender | |
h | Nama Penjamin | Patient |
Patient.contact.name.text |
|
i | Nomor Telepon Penjamin | Patient | Patient.contact.telecom.system | |
Patient.contact.telecom.value | ||||
Patient.contact.telecom.use | ||||
j | Ruangan / Kelas / Poli | Encounter | Encounter.location | |
k | Nama Dokter Penanggung Jawab Pelayanan (DPJP) | Encounter | Encounter.participant | |
2 | Tanggal dan Waktu Masuk | |||
a | Tanggal Masuk | Encounter | Encounter.period.start | |
b | Jam masuk | Encounter | Encounter.period.start | |
3 | Tanggal dan Waktu Discharge Administrasi | |||
a | Tanggal Discharge Administrasi | Encounter | Encounter.period.end | |
b | Jam Discharge Administrasi | Encounter | Encounter.period.end | |
4 | Diagnosis | |||
a | Diagnosis Awal / Masuk | Encounter | Encounter.diagnosis.condition | |
Encounter.diagnosis.use | ||||
Condition | Condition.code | |||
b | Diagnosis Akhir / Keluar | |||
|
Encounter | Encounter.diagnosis.condition | ||
Encounter.diagnosis.use | ||||
Encounter.diagnosis.rank | ||||
Condition | Condition.code | |||
|
Encounter | Encounter.diagnosis.condition.code | ||
Encounter.diagnosis.use | ||||
Encounter.diagnosis.rank | ||||
Condition | Condition.code | |||
5 | Pemeriksaan Penunjang | |||
a | Laboratorium | Observation | Observation.category.coding | |
Observation.code.coding | ||||
Observation.value[x] | ||||
6 | Tindakan / Prosedur Medis | Procedure | Procedure.code.coding | |
Procedure.category.coding | ||||
7 | Obat-obatan / Terapi | |||
a | Nama Obat | Medication | Medication.code | |
MedicationRequest | MedicationRequest.medicationReference | |||
b | Bentuk / Sediaan | Medication | Medication.form | |
MedicationRequest | MedicationRequest.medicationReference | |||
c | Jumlah Obat | MedicationRequest | MedicationRequest.dispenseRequest.quantity | |
d | Metode / Rute Pemberian | MedicationRequest | MedicationRequest.dosageInstruction.route | |
e | Dosis Obat yang Diberikan | MedicationRequest | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.value | |
f | Unit | MedicationRequest | MedicationRequest.dosageInstruction.doseAndRate.doseQuantity.unit | |
g | Frekuensi / Interval | MedicationRequest | MedicationRequest.dosageInstruction.timing | |
h | Aturan Tambahan | MedicationRequest | MedicationRequest.dosageInstruction.additionalInstruction.coding | |
MedicationRequest.dosageInstruction.additionalInstruction.text | ||||
8 | Diet | Composition | Composition.type | |
Composition.section.code.coding | ||||
Composition.text.status | ||||
Composition.text.div | ||||
9 | Alergi | AllergyIntolerance | AllergyIntolerance.category.coding | |
AllergyIntolerance.code.coding | ||||
10 | Prognosis | ClinicalImpression | ClinicalImpression.prognosisCodeableConcept.coding | |
11 | Kondisi Saat Meninggalkan Rumah Sakit | Condition | Condition.code | |
Encounter | Encounter.hospitalization.dischargeDisposition | |||
12 | Tingkat Kesadaran | Observation | Observation.category.coding | |
Observation.code.coding | ||||
Observation.valueCodeableConcept.coding | ||||
13 | Keadaan umum | |||
a | Vital Sign | |||
|
Observation | Observation.category.coding | ||
Observation.code.coding | ||||
Observation.valueQuantity | ||||
|
Observation | Observation.category.coding | ||
Observation.code.coding | ||||
Observation.valueQuantity | ||||
|
||||
*Sistole | Observation | Observation.category.coding | ||
Observation.code.coding | ||||
Observation.valueQuantity | ||||
*Diastole | Observation | Observation.category.coding | ||
Observation.code.coding | ||||
Observation.valueQuantity | ||||
|
Observation | Observation.category.coding | ||
Observation.code.coding | ||||
Observation.valueQuantity | ||||
14 | Rencana Tindak Lanjut / Cara Keluar dari Rumah Sakit | Encounter | Encounter.hospitalization.dischargeDisposition | |
ServiceRequest | ServiceRequest.code.coding | |||
15 | Obat yang Dibawa Pulang | |||
a | Nama Obat | Medication | Medication.code | |
MedicationDispense | MedicationDispense.medicationReference | |||
b | Bentuk / Sediaan | Medication | Medication.form | |
MedicationDispense | MedicationDispense.medicationReference | |||
c | Jumlah Obat | MedicationDispense | MedicationDispense.quantity | |
d | Metode / Rute Pemberian | MedicationDispense | MedicationDispense.dosageInstruction.route | |
e | Dosis Obat yang Diberikan | MedicationDispense | MedicationDispense.dosageInstruction.doseAndRate.doseQuantity.value | |
f | Unit | MedicationDispense | MedicationDispense.dosageInstruction.doseAndRate.doseQuantity.unit | |
g | Frekuensi / Interval | MedicationDispense | MedicationDispense.dosageInstruction.timing | |
h | Aturan Tambahan | MedicationDispense | MedicationDispense.dosageInstruction.additionalInstruction.coding | |
MedicationDispense.dosageInstruction.additionalInstruction.text | ||||
16 | Instruksi untuk Tindak Lanjut | |||
a | Kontrol ke | ServiceRequest | ServiceRequest.performer.organization ServiceRequest.performer.locationReference ServiceRequest.performer.locationCode | |
b | Tanggal | ServiceRequest.occurenceDateTime | ||
c | Dalam Keadaan Darurat dapat Menghubungi | ServiceRequest.patientInstruction | ||
17 | Edukasi | Procedure | Procedure.code.coding | |
18 | Sarana Transportasi Untuk Rujuk | ServiceRequest | ServiceRequest.locationCode | |
19 | Pasien / Penanggung Jawab (Nama dan Tanda Tangan) | Encounter | Encounter.subject | |
20 | Dokter Penanggung Jawab Pelayanan (Nama dan Tanda Tangan) | Encounter | Encounter.participant Encounter.participant.type |
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.id
dan identitas nama poliklinik. - Identitas Practitioner yang disimpan pada Sistem Informasi Fasyankes berupa
Practitioner IHS Number
dan 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 | {{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 |
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 |
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 |
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 |
statusHistory |
status : in-progress |
period |
start : 2022-06-14T08:00:00+07:00 |
end : 2022-06-14T09:00:00+07:00 |
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 |
{ "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 |
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 |
{ "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 |
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 |
{ "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" } }