Maternal Health Record
The "Maternal Health Record" relates to the perinatal period (during and after pregnancy) of a patient's history. In Malaysia government practice, maternal health records are kept as a physical document by patient (another copy stored by the facility). This flow allows continuation of care between one facility to another to naturally occur during a patient perinatal visits.
The maternal health record in RekodPesakit and RekodSaya attempts to replicate the concept in the form of a digital record retaining as much resemblance of the physical flow while still allowing the concept of record sharing between facilities.
Below is an overview diagram to illustrate how FHIR resource are used for maternal health record,
Resource Breakdown
Every maternal health record requires List (MY Core) record as a base panel to referene every record related to the current perinatal episode.
List Example
{ "resourceType": "List", "id": "list-sample", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/List-my-core" ] }, "status": "current", "mode": "working", "title": "Maternal Health Record 12-Sep-2023", "code": { "coding": [ { "system": "http://fhir.hie.moh.gov.my/CodeSystem/sub-record-type-my-core", "code": "sub-001", "display": "Maternal Health Record" } ] }, "subject": { "reference": "Patient/dba06121-c9c3-4169-bb92-b67a6f337ded/_history/4" }, "date": "2023-09-12T01:34:38.641Z", "source": { "reference": "PractitionerRole/121d966a-ca39-44dd-8e49-345f5ef1e484/_history/1" }, "entry": [ { "item": { "reference": "Patient/dba06121-c9c3-4169-bb92-b67a6f337ded/_history/4", "display": "Patient" } } ] }
The List must conform to List (MY Core) with;
- A source declaring main source system
meta.source - MY Core profile declared
meta.profile="http://fhir.hie.moh.gov.my/StructureDefinition/List-my-core" - The status as "current"
status="current" - The mode as "working"
mode="working" - A code to define maternal record "sub-001"
code.coding.code="sub-001" - Title defined as "Maternal Health Record DD-MMM-YYYY"
- e.g.
title:"Maternal Health Record 01-Sep-2023"
- e.g.
- The patient referenced as a subject
subject.referencewith history version stored- e.g.
subject.reference:"Patient/dba06121-c9c3-4169-bb92-b67a6f337ded/_history/4"
- e.g.
- The date when record created
date - entry referencing the patient
entry.item.reference
Referring to
Command 'pagelink' could not render: Page not found.
, the Maternal Health Record are generally broken down into a few categories;
- QuestionnaireResponse only
- QuestionnaireResponse + Composition
- Observation
QuestionnaireResponse Only
The main record are mostly stored as QuestionnaireResponse (MY Core) conforming to each defined
Command 'pagelink' could not render: Page not found.
pages.
It is advisable to send as a bundle with both QuestionnaireResponse and List referencing the QuestionnaireResponse as example below:
QuestionnaireResponse only
{ "resourceType": "Bundle", "type": "transaction", "entry": [ { "request": { "method": "PUT", "url": "List/list-sample" }, "resource": { "resourceType": "List", "id": "list-sample", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/List-my-core" ] }, "status": "current", "mode": "working", "title": "Maternal Health Record 12-Sep-2023", "code": { "coding": [ { "system": "http://fhir.hie.moh.gov.my/CodeSystem/sub-record-type-my-core", "code": "sub-001", "display": "Maternal Health Record" } ] }, "subject": { "reference": "Patient/dba06121-c9c3-4169-bb92-b67a6f337ded/_history/4" }, "date": "2023-09-12T01:34:38.641Z", "source": { "reference": "PractitionerRole/121d966a-ca39-44dd-8e49-345f5ef1e484/_history/1" }, "entry": [ { "item": { "reference": "Patient/dba06121-c9c3-4169-bb92-b67a6f337ded/_history/4", "display": "Patient" } }, { "date": "2023-09-12T09:34:41+08:00", "item": { "reference": "QuestionnaireResponse/qr-maternal-01-sample", "display": "maternal-01" } } ] } }, { "request": { "method": "PUT", "url": "QuestionnaireResponse/qr-maternal-01-sample" }, "resource": { "resourceType": "QuestionnaireResponse", "id": "qr-maternal-01-sample", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "identifier": { "system": "http://fhir.hie.moh.gov.my/sid/template-section", "value": "qr-maternal-01" }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-01", "status": "completed", "subject": { "reference": "Patient/dba06121-c9c3-4169-bb92-b67a6f337ded/_history/4" }, "authored": "2023-09-12T09:34:41+08:00", "item": [ { "linkId": "maternal-1.1", "text": "THA (LNMP)", "answer": [ { "valueDate": "2023-08-01", "item": [ { "linkId": "maternal-1.1.1", "text": "Unsure Date", "answer": [ { "valueBoolean": true } ] } ] } ] }, { "linkId": "maternal-1.2", "text": "TAL (EDD)", "answer": [ { "valueDate": "2024-05-07" } ] }, { "linkId": "maternal-1.3", "text": "RE EDD", "answer": [ { "valueDate": "2024-05-14" } ] }, { "linkId": "maternal-1.4", "text": "Gravida", "answer": [ { "valueInteger": 3 } ] }, { "linkId": "maternal-1.5", "text": "Para", "answer": [ { "valueInteger": 2, "item": [ { "linkId": "maternal-1.5.1", "text": "+", "answer": [ { "valueInteger": 1 } ] }, { "linkId": "maternal-1.5.2", "text": "Para remark", "answer": [ { "valueString": "miscarriage" } ] } ] } ] }, { "linkId": "maternal-1.6", "text": "Jururawat Y/M", "answer": [ { "valueReference": { "reference": "PractitionerRole/121d966a-ca39-44dd-8e49-345f5ef1e484", "display": "SAIFULDAULAH BIN MOHD HAFIZ NGOO ( Medical Officer )" } }, { "valueReference": { "reference": "PractitionerRole/19c428c2-21aa-4494-b416-22bd51de90d7", "display": "ZULAIKA ( Medical Officer )" } } ] }, { "linkId": "maternal-1.8", "text": "Height", "answer": [ { "valueQuantity": { "value": 168 } } ] }, { "linkId": "maternal-1.9", "text": "Booking Weight", "answer": [ { "valueQuantity": { "value": 55 } } ] }, { "linkId": "maternal-1.10", "text": "BMI", "answer": [ { "valueQuantity": { "value": 19.49 } } ] }, { "linkId": "maternal-1.11", "text": "BMI category", "answer": [ { "valueCoding": { "code": "310252000", "display": "Kurang Berat Badan (BMI < 20)" } } ] } ] } } ] }
The List must conform to List (MY Core) as mentioned above.
The QuestionnaireResponse must conform to QuestionnaireResponse (MY Core) with;
- A source declaring main source system
meta.source - MY Core profile declared
meta.profile="http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" - An identifier of the related page "qr-maternal-[pageNo]"
- e.g.
identifier.system="qr-maternal-01"
- e.g.
- A reference to the questionnaire
- e.g.
questionnaire: "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-01"
- e.g.
- A status as "completed"
status="completed"- e.g.
title:"Maternal Health Record 01-Sep-2023"
- e.g.
- The patient referenced as a subject
subject.reference - The date when record created
authored
These are the pages that stores as a QuestionnaireResponse only;
Click MY Core postman API link to view common API used in HIE.
| No | Title | JSON |
|---|---|---|
| 1. | Rekod Kesihatan Ibu |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-01", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-01", "version": "maternal-1.0.0", "name": "QMaternal01", "title": "Rekod Kesihatan Ibu", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "item": [ { "linkId": "maternal-1.1", "text": "THA (LNMP)", "type": "date", "item": [ { "linkId": "maternal-1.1.1", "text": "Unsure Date", "type": "boolean" } ] }, { "linkId": "maternal-1.2", "text": "TAL (EDD)", "type": "date" }, { "linkId": "maternal-1.3", "text": "RE EDD", "type": "date" }, { "linkId": "maternal-1.4", "text": "Gravida", "type": "integer" }, { "linkId": "maternal-1.5", "text": "Para", "type": "integer", "item": [ { "linkId": "maternal-1.5.1", "text": "+", "type": "integer" }, { "linkId": "maternal-1.5.2", "text": "Para remark", "type": "string", "maxLength": 20 } ] }, { "linkId": "maternal-1.6", "text": "Jururawat Y/M", "type": "reference", "repeats": true }, { "linkId": "maternal-1.7", "text": "Postnatal Address", "type": "string" }, { "linkId": "maternal-1.8", "text": "Height", "type": "quantity" }, { "linkId": "maternal-1.9", "text": "Booking Weight", "type": "quantity" }, { "linkId": "maternal-1.10", "text": "BMI", "type": "quantity" }, { "linkId": "maternal-1.11", "text": "BMI category", "type": "choice", "answerOption": [ { "valueCoding": { "code": "310252000", "display": "Kurang Berat Badan (BMI < 20)" } }, { "valueCoding": { "code": "35425004", "display": "Normal (BMI 20 -24)" } }, { "valueCoding": { "code": "162863004", "display": "Lebih Berat Badan (BMI 25 - 29)" } }, { "valueCoding": { "code": "162864005", "display": "Obese (BMI > 30)" } }, { "valueCoding": { "code": "408512008", "display": "Extreme Obese (BMI > 40)" } } ] }, { "linkId": "maternal-1.12", "text": "Post Natal Record", "type": "boolean" } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-01", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "questionnaire": "http://fhir.hie.moh.gov.my/baseR4/Questionnaire/q-maternal-01", "status": "completed", "subject": { "reference": "Patient/f92c383f-68de-46c1-8cde-970efa2d0f15/_history/1" }, "authored": "2023-01-01T04:14:25+08:00", "item": [ { "linkId": "maternal-1.1", "text": "THA (LNMP)", "answer": [ { "valueDate": "2023-08-01", "item": [ { "linkId": "maternal-1.1.1", "text": "Unsure Date", "answer": [ { "valueBoolean": true } ] } ] } ] }, { "linkId": "maternal-1.2", "text": "TAL (EDD)", "answer": [ { "valueDate": "2024-05-07" } ] }, { "linkId": "maternal-1.3", "text": "RE EDD", "answer": [ { "valueDate": "2024-05-14" } ] }, { "linkId": "maternal-1.4", "text": "Gravida", "answer": [ { "valueInteger": 3 } ] }, { "linkId": "maternal-1.5", "text": "Para", "answer": [ { "valueInteger": 2, "item": [ { "linkId": "maternal-1.5.1", "text": "+", "answer": [ { "valueInteger": 1 } ] }, { "linkId": "maternal-1.5.2", "text": "Para remark", "answer": [ { "valueString": "miscarriage" } ] } ] } ] }, { "linkId": "maternal-1.6", "text": "Jururawat Y/M", "answer": [ { "valueReference": { "reference": "PractitionerRole/121d966a-ca39-44dd-8e49-345f5ef1e484", "display": "SAIFULDAULAH BIN MOHD HAFIZ NGOO ( Medical Officer )" } }, { "valueReference": { "reference": "PractitionerRole/19c428c2-21aa-4494-b416-22bd51de90d7", "display": "ZULAIKA ( Medical Officer )" } } ] }, { "linkId": "maternal-1.8", "text": "Height", "answer": [ { "valueQuantity": { "value": 168 } } ] }, { "linkId": "maternal-1.9", "text": "Booking Weight", "answer": [ { "valueQuantity": { "value": 55 } } ] }, { "linkId": "maternal-1.10", "text": "BMI", "answer": [ { "valueQuantity": { "value": 19.49 } } ] }, { "linkId": "maternal-1.11", "text": "BMI category", "answer": [ { "valueCoding": { "code": "310252000", "display": "Kurang Berat Badan (BMI < 20)" } } ] } ] } |
| 2. | Perihal Kandungan Lalu |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-02", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-02", "version": "1.0.0", "name": "QMaternal02", "title": "Perihal Kandungan Lalu", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "item": [ { "linkId": "maternal-2.0", "text": "Perihal kandungan lalu", "type": "group", "repeats": true, "item": [ { "linkId": "maternal-2.1", "text": "Perihal kandungan lalu", "type": "group", "repeats": true, "item": [ { "linkId": "maternal-2.1.1", "text": "Tahun", "type": "date" }, { "linkId": "maternal-2.1.2", "text": "Hasil Kandungan", "type": "string" }, { "linkId": "maternal-2.1.3", "text": "Jenis Kelahiran", "type": "string" }, { "linkId": "maternal-2.1.4", "text": "Tempat", "type": "string" }, { "linkId": "maternal-2.1.5", "text": "Disambut Oleh", "type": "string" }, { "linkId": "maternal-2.1.6", "text": "Jantina", "type": "choice", "answerOption": [ { "valueCoding": { "system": "http://hl7.org/fhir/administrative-gender", "code": "male", "display": "Lelaki" } }, { "valueCoding": { "system": "http://hl7.org/fhir/administrative-gender", "code": "female", "display": "Perempuan" } } ] }, { "linkId": "maternal-2.1.7", "text": "Berat Lahir", "type": "quantity" }, { "linkId": "maternal-2.1.8", "text": "Komplikasi Ibu", "type": "string" }, { "linkId": "maternal-2.1.9", "text": "Komplikasi Anak", "type": "string" }, { "linkId": "maternal-2.1.10", "text": "Penyusuan susu ibu/tempoh", "type": "string" }, { "linkId": "maternal-2.1.11", "text": "Keadaan anak sekarang", "type": "string" } ] } ] }, { "linkId": "maternal-2.2", "text": "Tarikh Perkahwinan", "type": "date", "repeats": true } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-02", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "identifier": { "system": "http://fhir.hie.moh.gov.my/sid/template-section", "value": "qr-maternal-02" }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-02", "status": "completed", "subject": { "reference": "Patient/bfb81ffe-637d-4b3f-befa-f7a1546ed9f8" }, "authored": "2022-11-16T03:56:06.596Z", "item": [ { "linkId": "maternal-2.0", "text": "Perihal kandungan lalu", "item": [ { "linkId": "maternal-2.1", "text": "Perihal kandungan lalu", "item": [ { "linkId": "maternal-2.1.1", "text": "Tahun", "answer": [ { "valueDate": "2020-08-05" } ] }, { "linkId": "maternal-2.1.2", "text": "Hasil Kandungan", "answer": [ { "valueString": "1" } ] }, { "linkId": "maternal-2.1.3", "text": "Jenis Kelahiran", "answer": [ { "valueString": "kembar 1" } ] }, { "linkId": "maternal-2.1.4", "text": "Tempat", "answer": [ { "valueString": "tempat entry 1" } ] }, { "linkId": "maternal-2.1.5", "text": "Disambut Oleh", "answer": [ { "valueString": "disambut entry 1" } ] }, { "linkId": "maternal-2.1.6", "text": "Jantina", "answer": [ { "valueCoding": { "system": "http://hl7.org/fhir/administrative-gender", "code": "male", "display": "Lelaki" } } ] }, { "linkId": "maternal-2.1.7", "text": "Berat Lahir", "answer": [ { "valueQuantity": { "value": 2 } } ] }, { "linkId": "maternal-2.1.8", "text": "Komplikasi Ibu", "answer": [ { "valueString": "komplikasi ibu entry 1" } ] }, { "linkId": "maternal-2.1.9", "text": "Komplikasi Anak", "answer": [ { "valueString": "komplikasi anak entry 1" } ] }, { "linkId": "maternal-2.1.10", "text": "Penyusuan susu ibu/tempoh", "answer": [ { "valueString": "1" } ] }, { "linkId": "maternal-2.1.11", "text": "Keadaan anak sekarang", "answer": [ { "valueString": "keadaan entry 1" } ] } ] }, { "linkId": "maternal-2.1", "text": "Perihal kandungan lalu", "item": [ { "linkId": "maternal-2.1.1", "text": "Tahun", "answer": [ { "valueDate": "2020-08-05" } ] }, { "linkId": "maternal-2.1.2", "text": "Hasil Kandungan", "answer": [ { "valueString": "1" } ] }, { "linkId": "maternal-2.1.3", "text": "Jenis Kelahiran", "answer": [ { "valueString": "kembar 2" } ] }, { "linkId": "maternal-2.1.4", "text": "Tempat", "answer": [ { "valueString": "tempat entry 2" } ] }, { "linkId": "maternal-2.1.5", "text": "Disambut Oleh", "answer": [ { "valueString": "disambut entry 2" } ] }, { "linkId": "maternal-2.1.6", "text": "Jantina", "answer": [ { "valueCoding": { "system": "http://hl7.org/fhir/administrative-gender", "code": "female", "display": "Perempuan" } } ] }, { "linkId": "maternal-2.1.7", "text": "Berat Lahir", "answer": [ { "valueQuantity": { "value": 2 } } ] }, { "linkId": "maternal-2.1.8", "text": "Komplikasi Ibu", "answer": [ { "valueString": "komplikasi ibu entry 2" } ] }, { "linkId": "maternal-2.1.9", "text": "Komplikasi Anak", "answer": [ { "valueString": "komplikasi anak entry 2" } ] }, { "linkId": "maternal-2.1.10", "text": "Penyusuan susu ibu/tempoh", "answer": [ { "valueString": "2" } ] }, { "linkId": "maternal-2.1.11", "text": "Keadaan anak sekarang", "answer": [ { "valueString": "keadaan entry 2" } ] } ] } ] }, { "linkId": "maternal-2.0", "text": "Perihal kandungan lalu", "item": [ { "linkId": "maternal-2.1", "text": "Perihal kandungan lalu", "item": [ { "linkId": "maternal-2.1.1", "text": "Tahun", "answer": [ { "valueDate": "2023-08-05" } ] }, { "linkId": "maternal-2.1.2", "text": "Hasil Kandungan", "answer": [ { "valueString": "1" } ] }, { "linkId": "maternal-2.1.3", "text": "Jenis Kelahiran", "answer": [ { "valueString": "bukan kembar" } ] }, { "linkId": "maternal-2.1.4", "text": "Tempat", "answer": [ { "valueString": "tempat entry 3" } ] }, { "linkId": "maternal-2.1.5", "text": "Disambut Oleh", "answer": [ { "valueString": "disambut entry 3" } ] }, { "linkId": "maternal-2.1.6", "text": "Jantina", "answer": [ { "valueCoding": { "system": "http://hl7.org/fhir/administrative-gender", "code": "male", "display": "Lelaki" } } ] }, { "linkId": "maternal-2.1.7", "text": "Berat Lahir", "answer": [ { "valueQuantity": { "value": 2 } } ] }, { "linkId": "maternal-2.1.8", "text": "Komplikasi Ibu", "answer": [ { "valueString": "komplikasi ibu entry 3" } ] }, { "linkId": "maternal-2.1.9", "text": "Komplikasi Anak", "answer": [ { "valueString": "komplikasi anak entry 3" } ] }, { "linkId": "maternal-2.1.10", "text": "Penyusuan susu ibu/tempoh", "answer": [ { "valueString": "1" } ] }, { "linkId": "maternal-2.1.11", "text": "Keadaan anak sekarang", "answer": [ { "valueString": "keadaan entry 3" } ] } ] } ] }, { "linkId": "maternal-2.2", "text": "Tarikh Perkahwinan", "answer": [ { "valueDate": "2003-08-06" }, { "valueDate": "2019-07-31" } ] } ] } |
| 3. | Riwayat Kesihatan Ibu Dan Keluarga |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-03", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-03", "version": "1.0.0", "name": "QMaternal03", "title": "Riwayat Kesihatan Ibu Dan Keluarga", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "item": [ { "linkId": "maternal-3.1", "text": "Haid", "type": "group", "item": [ { "linkId": "maternal-3.1.1", "text": "Jumlah Hari", "type": "quantity" }, { "linkId": "maternal-3.1.2", "text": "Pusingan", "type": "choice", "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "78456001", "display": "Teratur" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "80182007", "display": "Tidak teratur" } } ] } ] }, { "linkId": "maternal-3.2", "text": "Amalan Perancang Keluarga", "type": "group", "required": true, "item": [ { "linkId": "maternal-3.2.1", "text": "Mengamal perancang keluarga", "type": "boolean" }, { "linkId": "maternal-3.2.2", "text": "Kaedah", "type": "choice", "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "225370004", "display": "Barrier Method" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "89639000", "display": "Cervical cap and diaphragm" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "268463003", "display": "Coitus Interruptus" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "102954005", "display": "Emergency Contraception" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "137531000119108", "display": "Hormonal patch" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "449038007", "display": "Implant" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "268464009", "display": "Injectables" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "449038007", "display": "Intrauterine Contraception (Hormonal)" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "312079003", "display": "Intrauterine Contraception (Non-Hormonal)" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "237122005", "display": "Lactation Amenorrhoea Methods" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "5935008", "display": "Oral Contraceptives" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "225371000", "display": "Other natural methods" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "268466006", "display": "Spermicidal Contraception" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "137521000119105", "display": "Vaginal Ring" } } ] }, { "linkId": "maternal-3.2.3", "text": "Berapa lama", "type": "quantity" } ] }, { "linkId": "maternal-3.3", "text": "Status Merokok", "type": "group", "item": [ { "linkId": "maternal-3.3.1", "text": "Ibu", "type": "boolean" }, { "linkId": "maternal-3.3.2", "text": "Suami", "type": "boolean" }, { "linkId": "maternal-3.3.3", "text": "Remark Status Merokok", "type": "text" } ] }, { "linkId": "maternal-3.4", "text": "Masalah Perubatan Ibu", "type": "group", "item": [ { "linkId": "maternal-3.4.1", "text": "Masalah Perubatan Ibu", "type": "choice", "repeats": true, "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "73211009", "display": "Diabetes" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "195967001", "display": "Asma" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "40108008", "display": "Thalasemia" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "19442009", "display": "Thalasemia Carrier" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "38341003", "display": "Hipertensi" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "49601007", "display": "Sakit Jantung" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "14304000", "display": "Tiroid" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "609328004", "display": "Alergi" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "56717001", "display": "Tibi" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "363346000", "display": "Kanser" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "74732009", "display": "Psikiatri" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "271737000", "display": "Anemia" } } ] }, { "linkId": "maternal-3.4.2", "text": "Lain-lain Masalah Perubatan Ibu", "type": "string" } ] }, { "linkId": "maternal-3.5", "text": "Saringan Tibi", "type": "group", "item": [ { "linkId": "maternal-3.5.1", "text": "Adakah anda mengalami batuk lebih 2 minggu", "type": "boolean" } ] }, { "linkId": "maternal-3.6", "text": "Masalah Perubatan Keluarga", "type": "group", "item": [ { "linkId": "maternal-3.6.1", "text": "Masalah Perubatan Keluarga", "type": "choice", "repeats": true, "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "73211009", "display": "Diabetes" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "195967001", "display": "Asma" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "271737000", "display": "Anemia" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "38341003", "display": "Hipertensi" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "49601007", "display": "Sakit Jantung" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "40108008", "display": "Thalasemia" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "19442009", "display": "Thalasemia Carrier" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "609328004", "display": "Alergi" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "56717001", "display": "Tibi" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "74732009", "display": "Psikiatri" } } ] }, { "linkId": "maternal-3.6.2", "text": "Lain-lain Masalah Perubatan Keluarga", "type": "string" } ] }, { "linkId": "maternal-3.7", "text": "Status Imunisasi Ibu", "type": "group", "repeats": true, "item": [ { "linkId": "maternal-3.7.1", "text": "Jenis/Dos vaksin", "type": "string" }, { "linkId": "maternal-3.7.2", "text": "Tarikh suntikan", "type": "dateTime" }, { "linkId": "maternal-3.7.3", "text": "Batch No", "type": "string" }, { "linkId": "maternal-3.7.4", "text": "Tarikh Luput", "type": "dateTime" } ] } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-03", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/qr-maternal-03", "status": "completed", "subject": { "reference": "Patient/bfb81ffe-637d-4b3f-befa-f7a1546ed9f8" }, "authored": "2022-11-16T03:56:06.596Z", "item": [ { "linkId": "maternal-3.1", "text": "Haid", "item": [ { "linkId": "maternal-3.1.1", "text": "Jumlah Hari", "answer": [ { "valueQuantity": { "value": 1, "unit": "month" } } ] }, { "linkId": "maternal-3.1.2", "text": "Pusingan", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "78456001", "display": "Teratur" } } ] } ] }, { "linkId": "maternal-3.2", "text": "Amalan Perancang Keluarga", "item": [ { "linkId": "maternal-3.2.1", "text": "Mengamal perancang keluarga", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-3.2.2", "text": "Kaedah", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "225370004", "display": "Barrier Method" } } ] }, { "linkId": "maternal-3.2.3", "text": "Berapa lama", "answer": [ { "valueQuantity": { "value": 1, "unit": "month" } } ] } ] }, { "linkId": "maternal-3.3", "text": "Status Merokok", "item": [ { "linkId": "maternal-3.3.1", "text": "Ibu", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-3.3.2", "text": "Suami", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-3.3.3", "text": "Remark Status Merokok", "answer": [ { "valueString": "Remark status merokok goes here" } ] } ] }, { "linkId": "maternal-3.4", "text": "Masalah Perubatan Ibu", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "73211009", "display": "Diabetes" }, "item": [ { "linkId": "5876813438457", "text": "Lain-lain", "answer": [ { "valueString": "Right Kidney Failure" } ] } ] }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "195967001", "display": "Asma" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "40108008", "display": "Thalasemia" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "56717001", "display": "Tibi" } } ] }, { "linkId": "maternal-3.5", "text": "Saringan Tibi", "item": [ { "linkId": "maternal-3.5.1", "text": "Adakah anda mengalami batuk lebih 2 minggu", "answer": [ { "valueBoolean": true } ] } ] }, { "linkId": "maternal-3.6", "text": "Masalah Perubatan Keluarga", "item": [ { "linkId": "maternal-3.6.1", "text": "Masalah Perubatan Keluarga", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "195967001", "display": "Asma" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "74732009", "display": "Psikiatri" } } ] }, { "linkId": "maternal-3.6.2", "text": "Lain-lain", "answer": [ { "valueString": "Buta Warna" } ] } ] }, { "linkId": "maternal-3.7", "text": "Status Imunisasi Ibu", "item": [ { "linkId": "maternal-3.7.1", "text": "Jenis/Dos vaksin", "answer": [ { "valueString": "Tetanus/Toxoid" } ] }, { "linkId": "maternal-3.7.2", "text": "Tarikh suntikan", "answer": [ { "valueDateTime": "2022-11-16T09:29:51.092Z" } ] }, { "linkId": "maternal-3.7.3", "text": "Batch No", "answer": [ { "valueString": "1" } ] }, { "linkId": "maternal-3.7.4", "text": "Tarikh Luput", "answer": [ { "valueDateTime": "2022-11-16T09:30:07.668Z" } ] } ] }, { "linkId": "maternal-3.7", "text": "Status Imunisasi Ibu", "item": [ { "linkId": "maternal-3.7.1", "text": "Jenis/Dos vaksin", "answer": [ { "valueString": "Covid-19" } ] }, { "linkId": "maternal-3.7.2", "text": "Tarikh suntikan", "answer": [ { "valueDateTime": "2022-11-16T09:30:40.231Z" } ] }, { "linkId": "maternal-3.7.3", "text": "Batch No", "answer": [ { "valueString": "2" } ] }, { "linkId": "maternal-3.7.4", "text": "Tarikh Luput", "answer": [ { "valueDateTime": "2022-11-16T09:30:46.725Z" } ] } ] } ] } |
| 4. | Akuan Pengambilan Darah bagi Ujian Saringan Antenatal | Consent not stored in HIE |
| 5. | Penyakit/status yang disaring |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-05", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-05", "version": "1.0.0", "name": "QMaternal05", "title": "Penyakit/status yang disaring", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "item": [ { "linkId": "maternal-5.1", "text": "Kumpulan darah & Rhesus", "type": "group", "item": [ { "linkId": "maternal-5.1.1", "text": "Tarikh diambil", "type": "dateTime" }, { "linkId": "maternal-5.1.2", "text": "Keputusan", "type": "string" } ] }, { "linkId": "maternal-5.2", "text": "Syphilis", "type": "group", "repeats": true, "item": [ { "linkId": "maternal-5.2.1", "text": "Tarikh diambil", "type": "dateTime" }, { "linkId": "maternal-5.2.2", "text": "Keputusan", "type": "choice", "answerOption": [ { "valueCoding": { "code": "a1", "display": "Positive" } }, { "valueCoding": { "code": "a2", "display": "Negative" } }, { "valueCoding": { "code": "a3", "display": "Pending" } } ] } ] }, { "linkId": "maternal-5.3", "text": "HIV", "type": "group", "repeats": true, "item": [ { "linkId": "maternal-5.3.1", "text": "Tarikh diambil", "type": "dateTime" }, { "linkId": "maternal-5.3.2", "text": "Keputusan", "type": "choice", "answerOption": [ { "valueCoding": { "code": "a1", "display": "Positive" } }, { "valueCoding": { "code": "a2", "display": "Negative" } }, { "valueCoding": { "code": "a3", "display": "Pending" } } ] } ] }, { "linkId": "maternal-5.4", "text": "Hepatitis B", "type": "group", "repeats": true, "item": [ { "linkId": "maternal-5.4.1", "text": "Tarikh diambil", "type": "dateTime" }, { "linkId": "maternal-5.4.2", "text": "Keputusan", "type": "choice", "answerOption": [ { "valueCoding": { "code": "a1", "display": "Positive" } }, { "valueCoding": { "code": "a2", "display": "Negative" } }, { "valueCoding": { "code": "a3", "display": "Pending" } } ] } ] }, { "linkId": "maternal-5.5", "text": "Malaria (BFMP)", "type": "group", "item": [ { "linkId": "maternal-5.5.1", "text": "Tarikh diambil", "type": "dateTime" }, { "linkId": "maternal-5.5.2", "text": "Keputusan", "type": "string" } ] } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-05", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-05", "status": "completed", "subject": { "reference": "Patient/bfb81ffe-637d-4b3f-befa-f7a1546ed9f8" }, "authored": "2022-11-16T03:56:06.596Z", "item": [ { "linkId": "maternal-5.1", "text": "Kumpulan darah & Rhesus", "item": [ { "linkId": "maternal-5.1.1", "text": "Tarikh diambil", "answer": [ { "valueDateTime": "2022-11-06T06:21:30.609Z" } ] }, { "linkId": "maternal-5.1.2", "text": "Keputusan", "answer": [ { "valueString": "Negatif" } ] } ] }, { "linkId": "maternal-5.2", "text": "Syphilis", "item": [ { "linkId": "maternal-5.2.1", "text": "Tarikh diambil", "answer": [ { "valueDateTime": "2022-11-06T06:21:52.150Z" } ] }, { "linkId": "maternal-5.2.2", "text": "Keputusan", "answer": [ { "valueString": "Negatif" } ] } ] }, { "linkId": "maternal-5.3", "text": "HIV", "item": [ { "linkId": "maternal-5.3.1", "text": "Tarikh diambil", "answer": [ { "valueDateTime": "2022-11-06T06:22:19.917Z" } ] }, { "linkId": "maternal-5.3.2", "text": "Keputusan", "answer": [ { "valueString": "Negatif" } ] } ] }, { "linkId": "maternal-5.4", "text": "Hepatitis B", "item": [ { "linkId": "maternal-5.4.1", "text": "Tarikh diambil", "answer": [ { "valueDateTime": "2022-11-06T06:22:33.169Z" } ] }, { "linkId": "maternal-5.4.2", "text": "Keputusan", "answer": [ { "valueString": "Negatif" } ] } ] }, { "linkId": "maternal-5.5", "text": "Malaria (BFMP)", "item": [ { "linkId": "maternal-5.5.1", "text": "Tarikh diambil", "answer": [ { "valueDateTime": "2022-11-06T06:22:42.997Z" } ] }, { "linkId": "maternal-5.5.2", "text": "Keputusan", "answer": [ { "valueString": "Negatif" } ] } ] } ] } |
| 7. | Pemeriksaan Oleh Pegawai Perubatan dan Pegawai Pergigian |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-07", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-07", "version": "1.0.0", "name": "QMaternal07", "title": "Pemeriksaan Oleh Pegawai Perubatan dan Pegawai Pergigian", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "item": [ { "linkId": "maternal-7.1", "code": [ { "code": "maternal-7.1" } ], "text": "Jenis Pemeriksaan", "type": "choice", "answerOption": [ { "valueCoding": { "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core", "code": "maternal-rme-1", "display": "Routine Medical Exam 1 (RME 1)" } }, { "valueCoding": { "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core", "code": "maternal-rme-2", "display": "Routine Medical Exam 2 (RME 2)" } }, { "valueCoding": { "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core", "code": "maternal-rme-add", "display": "Additional Medical Exam" } }, { "valueCoding": { "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core", "code": "maternal-rme-dental", "display": "Dental Routine Medical Exam" } } ] }, { "linkId": "maternal-7.2", "text": "General", "type": "group", "item": [ { "linkId": "maternal-7.2.1", "text": "Pink/Pallor", "type": "string" }, { "linkId": "maternal-7.2.2", "text": "Jaundice", "type": "string" }, { "linkId": "maternal-7.2.3", "text": "BP", "type": "group", "item": [ { "linkId": "maternal-7.2.3.1", "text": "Systolic", "type": "quantity" }, { "linkId": "maternal-7.2.3.2", "text": "Diastolic", "type": "quantity" } ] }, { "linkId": "maternal-7.2.4", "text": "Pulse Rate", "type": "quantity" }, { "linkId": "maternal-7.2.5", "text": "Pulse Rhythm", "type": "string" } ] }, { "linkId": "maternal-7.3", "text": "Neck", "type": "group", "item": [ { "linkId": "maternal-7.3.1", "text": "Swelling", "type": "string" } ] }, { "linkId": "maternal-7.4", "text": "CVS", "type": "group", "item": [ { "linkId": "maternal-7.4.1", "text": "Clubbing", "type": "boolean" }, { "linkId": "maternal-7.4.2", "text": "JVP", "type": "choice", "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "260399008", "display": "Raised" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "17621005", "display": "Normal" } } ] }, { "linkId": "maternal-7.4.3", "text": "Apex Beat", "type": "choice", "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "17621005", "display": "Normal" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "263739008", "display": "Displaced" } } ] }, { "linkId": "maternal-7.4.4", "text": "Heart Sounds", "type": "choice", "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "301132007", "display": "Normal" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "123824001", "display": "Abnormal" } } ] } ] }, { "linkId": "maternal-7.5", "text": "Breast", "type": "choice", "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "17621005", "display": "Normal" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "263654008", "display": "Abnormal" } } ] }, { "linkId": "maternal-7.6", "text": "Lungs", "type": "choice", "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "17621005", "display": "Normal" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "263654008", "display": "Abnormal" } } ] }, { "linkId": "maternal-7.7", "text": "Abdomen", "type": "group", "item": [ { "linkId": "maternal-7.7.1", "text": "SFH", "type": "string" }, { "linkId": "maternal-7.7.2", "text": "FHR", "type": "quantity" } ] }, { "linkId": "maternal-7.8", "text": "Lower limbs", "type": "group", "item": [ { "linkId": "maternal-7.8.1", "text": "Oedema", "type": "boolean" }, { "linkId": "maternal-7.8.2", "text": "Calf tenderness", "type": "boolean" } ] }, { "linkId": "maternal-7.9", "text": "Catatan", "type": "text" } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-07", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-07", "status": "completed", "subject": { "reference": "Patient/bfb81ffe-637d-4b3f-befa-f7a1546ed9f8" }, "authored": "2022-11-23T00:42:29.983Z", "item": [ { "linkId": "maternal-7.1", "text": "Jenis Pemeriksaan", "answer": [ { "valueCoding": { "system": "http://fhir.hie.moh.gov.my/CodeSystem/composition-event-my-core", "code": "maternal-rme-1", "display": "Routine Medical Exam 1 (RME 1)" } } ] }, { "linkId": "maternal-7.2", "text": "General", "item": [ { "linkId": "maternal-7.2.1", "text": "Pink/Pallor", "answer": [ { "valueString": "pink" } ] }, { "linkId": "maternal-7.2.2", "text": "Jaundice", "answer": [ { "valueString": "normal" } ] }, { "linkId": "maternal-7.2.3", "text": "BP", "item": [ { "linkId": "maternal-7.2.3.1", "text": "Systolic", "answer": [ { "valueQuantity": { "value": 120 } } ] }, { "linkId": "maternal-7.2.3.2", "text": "Diastolic", "answer": [ { "valueQuantity": { "value": 90 } } ] } ] }, { "linkId": "maternal-7.2.4", "text": "Pulse Rate", "answer": [ { "valueQuantity": { "value": 90 } } ] }, { "linkId": "maternal-7.2.5", "text": "Pulse Rhythm", "answer": [ { "valueString": "regularly regular" } ] } ] }, { "linkId": "maternal-7.3", "text": "Neck", "item": [ { "linkId": "maternal-7.3.1", "text": "Swelling", "answer": [ { "valueString": "swelling over less left lower zone, not tethered to skin" } ] } ] }, { "linkId": "maternal-7.4", "text": "CVS", "item": [ { "linkId": "maternal-7.4.1", "text": "Clubbing", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-7.4.2", "text": "JVP", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "260399008", "display": "Raised" } } ] }, { "linkId": "maternal-7.4.3", "text": "Apex Beat", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "263739008", "display": "Displaced" } } ] }, { "linkId": "maternal-7.4.4", "text": "Heart Sounds", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "123824001", "display": "Abnormal" } } ] } ] }, { "linkId": "maternal-7.5", "text": "Breast", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "17621005", "display": "Normal" } } ] }, { "linkId": "maternal-7.6", "text": "Lungs", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "263654008", "display": "Abnormal" } } ] }, { "linkId": "maternal-7.7", "text": "Abdomen", "item": [ { "linkId": "maternal-7.7.1", "text": "SFH", "answer": [ { "valueQuantity": { "value": 35 } } ] }, { "linkId": "maternal-7.7.2", "text": "FHR", "answer": [ { "valueQuantity": { "value": 200 } } ] } ] }, { "linkId": "maternal-7.8", "text": "Lower limbs", "item": [ { "linkId": "maternal-7.8.1", "text": "Oedema", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-7.8.2", "text": "Calf tenderness", "answer": [ { "valueBoolean": true } ] } ] }, { "linkId": "maternal-7.9", "text": "Catatan", "answer": [ { "valueString": "Patient has multiple issues, need to be referral to hospital" } ] } ] } |
| 8. | Senarai Semak Kriteria Untuk Ujian Saringan OGTT |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-08", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-08", "version": "1.0.0", "name": "QMaternal08", "title": "Senarai Semak Kriteria Untuk Ujian Saringan OGTT", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "item": [ { "linkId": "maternal-8.1", "text": "BMI >27 kg/m2", "type": "boolean" }, { "linkId": "maternal-8.2", "text": "Sejarah Gestational Diabetes Mellitus (GDM)", "type": "boolean" }, { "linkId": "maternal-8.3", "text": "Sejarah keluarga terdekat dengan diabetes", "type": "boolean" }, { "linkId": "maternal-8.4", "text": "Sejarah melahirkan bayi macrosomia (berat bayi ≥4 kg)", "type": "boolean" }, { "linkId": "maternal-8.5", "text": "Bad Obstetric History: Sejarah kelahiran IUD/ Stillbirth, kecacatan kongenital (contoh : neural tube defects, cardiac defects), shoulder dystocia", "type": "boolean" }, { "linkId": "maternal-8.6", "text": "Glycosuria ≥ 2 kali", "type": "boolean" }, { "linkId": "maternal-8.7", "text": "Masalah obstetrik sekarang (Hypertensive disease in pregnancy, Polyhdramnios, menerima rawatan Corticosteriods)", "type": "boolean" }, { "linkId": "maternal-8.8", "text": "Umur ≥25 tahun (walaupun tanpa faktor risiko GDM yang lain)", "type": "boolean" } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-08", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-08", "status": "completed", "subject": { "reference": "Patient/bfb81ffe-637d-4b3f-befa-f7a1546ed9f8" }, "authored": "2022-11-23T00:42:29.983Z", "item": [ { "linkId": "maternal-8.1", "text": " BMI >27 kg/m2", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-8.2", "text": " Sejarah Gestational Diabetes Mellitus (GDM)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-8.3", "text": "Sejarah keluarga terdekat dengan diabetes", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-8.4", "text": " Sejarah melahirkan bayi macrosomia (berat bayi ≥4 kg)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-8.5", "text": "Bad Obstetric History: Sejarah kelahiran IUD/ Stillbirth, kecacatan kongenital (contoh : neural tube defects, cardiac defects), shoulder dystocia", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-8.6", "text": "Glycosuria ≥ 2 kali", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-8.7", "text": "Masalah obstetrik sekarang (Hypertensive disease in pregnancy, Polyhdramnios, menerima rawatan Corticosteriods)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-8.maternal-8", "text": "Umur ≥25 tahun (walaupun tanpa faktor risiko GDM yang lain)", "answer": [ { "valueBoolean": true } ] } ] } |
| 9. | Keputusan Ujian OGTT |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-09", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-09", "version": "1.0.0", "name": "QMaternal09", "title": "Keputusan Ujian OGTT", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "item": [ { "linkId": "maternal-9.1", "text": "Keputusan Ujian OGTT", "type": "group", "repeats": true, "item": [ { "linkId": "maternal-9.1.1", "text": "Tarikh", "type": "dateTime" }, { "linkId": "maternal-9.1.2", "text": "POG", "type": "quantity" }, { "linkId": "maternal-9.1.3", "text": "Fasting Blood Sugar", "type": "quantity" }, { "linkId": "maternal-9.1.4", "text": "2H Postprandial", "type": "quantity" } ] } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-09", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-09", "status": "completed", "subject": { "reference": "Patient/bfb81ffe-637d-4b3f-befa-f7a1546ed9f8" }, "authored": "2022-11-16T03:56:06.596Z", "item": [ { "linkId": "maternal-9.1", "text": "Tarikh", "answer": [ { "valueDateTime": "2022-11-16T00:54:04.078Z" } ] }, { "linkId": "maternal-9.2", "text": "POG", "answer": [ { "valueQuantity": { "value": 12 } } ] }, { "linkId": "maternal-9.3", "text": "Fasting Blood Sugar", "answer": [ { "valueQuantity": { "value": 12 } } ] }, { "linkId": "maternal-9.4", "text": "2H Postprandial", "answer": [ { "valueQuantity": { "value": 12 } } ] } ] } |
| 10. | Pemantauan Paras Gula Dalam Darah |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-10", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-10", "version": "1.0.0", "name": "QMaternal10", "title": "Pemantauan Paras Gula Dalam Darah", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "item": [ { "linkId": "maternal-10.1", "text": "Pemantauan Paras Gula Dalam Darah", "type": "group", "item": [ { "linkId": "maternal-10.1.1", "text": "Tarikh", "type": "dateTime" }, { "linkId": "maternal-10.1.2", "text": "Pre Breakfast", "type": "quantity" }, { "linkId": "maternal-10.1.3", "text": "2 Hours Post Breakfast", "type": "quantity" }, { "linkId": "maternal-10.1.4", "text": "Pre Lunch", "type": "quantity" }, { "linkId": "maternal-10.1.5", "text": "2 Hours Post Lunch", "type": "quantity" }, { "linkId": "maternal-10.1.6", "text": "Pre Dinner", "type": "quantity" }, { "linkId": "maternal-10.1.7", "text": "2 Hours Post Dinner", "type": "quantity" }, { "linkId": "maternal-10.1.8", "text": "Pre Bed", "type": "quantity" }, { "linkId": "maternal-10.1.9", "text": "Catatan", "type": "string" } ] } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-10", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "identifier": { "system": "http://fhir.hie.moh.gov.my/sid/template-section", "value": "qr-maternal-10" }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-10", "status": "completed", "subject": { "reference": "Patient/3a1fe467-cad5-4ec9-83f8-fd6dfb46470c" }, "authored": "2023-04-27T00:20:14.414Z", "author": { "reference": "PractitionerRole/08a661a4-2855-47e9-8e2e-cbb43f785ecf/_history/3" }, "item": [ { "linkId": "maternal-10.1", "text": "Pemantauan Paras Gula Dalam Darah", "item": [ { "linkId": "maternal-10.1.1", "text": "Tarikh", "answer": [ { "valueDateTime": "2023-06-07T05:12:37.828Z" } ] }, { "linkId": "maternal-10.1.2", "text": "Pre Breakfast", "answer": [ { "valueQuantity": { "value": 7.2 } } ] }, { "linkId": "maternal-10.1.3", "text": "2 Hours Post Breakfast", "answer": [ { "valueQuantity": { "value": 6.1 } } ] }, { "linkId": "maternal-10.1.4", "text": "Pre Lunch", "answer": [ { "valueQuantity": { "value": 6.2 } } ] }, { "linkId": "maternal-10.1.5", "text": "2 Hours Post Lunch", "answer": [ { "valueQuantity": { "value": 5 } } ] }, { "linkId": "maternal- 10.1.6", "text": "Pre Dinner", "answer": [ { "valueQuantity": { "value": 4.9 } } ] }, { "linkId": "maternal- 10.1.7", "text": "2 Hours Post Dinner", "answer": [ { "valueQuantity": { "value": 3.2 } } ] }, { "linkId": "maternal-10.1.8", "text": "Pre Bed", "answer": [ { "valueQuantity": { "value": 2 } } ] }, { "linkId": "maternal-10.1.6", "text": "Catatan", "answer": [ { "valueString": "enter string here" } ] } ] } ] } |
| 11. | Pemantauan Tekanan Darah |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-11", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-11", "version": "1.0", "name": "QMaternal11", "title": "Pemantauan Tekanan Darah", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "item": [ { "linkId": "maternal-11.1", "text": "Pemantauan Tekanan Darah", "type": "group", "repeats": true, "item": [ { "linkId": "maternal-11.1.1", "text": "Tarikh", "type": "date" }, { "linkId": "maternal-11.1.2", "text": "Masa", "type": "time" }, { "linkId": "maternal-11.1.3", "text": "Simptom", "type": "text" }, { "linkId": "maternal-11.1.4", "text": "Tekanan Darah", "type": "group", "item": [ { "linkId": "maternal-11.1.4.1", "text": "Sistolik", "type": "quantity" }, { "linkId": "maternal-11.1.4.2", "text": "Diastolik", "type": "quantity" } ] }, { "linkId": "maternal-11.1.5", "text": "Denyutan Jantung Janin", "type": "quantity" }, { "linkId": "maternal-11.1.6", "text": "Urin Protein", "type": "choice", "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "167273002", "display": "Not Detected" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "167274008", "display": "Trace" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "167275009", "display": "1+" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "167276005", "display": "2+" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "167277001", "display": "3+" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "167278006", "display": "4+" } } ] } ] } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-11", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-11", "status": "completed", "subject": { "reference": "Patient/bfb81ffe-637d-4b3f-befa-f7a1546ed9f8" }, "authored": "2022-11-16T03:56:06.596Z", "item": [ { "linkId": "maternal-11.1", "text": "Pemantauan Tekanan Darah", "item": [ { "linkId": "maternal-11.1.1", "text": "Tarikh", "answer": [ { "valueDate": "2022-11-15" } ] }, { "linkId": "maternal-11.1.2", "text": "Masa", "answer": [ { "valueTime": "14:00:50" } ] }, { "linkId": "maternal-11.1.3", "text": "Simptom", "answer": [ { "valueString": "Pitam" } ] }, { "linkId": "maternal-11.1.4", "text": "Tekanan Darah", "item": [ { "linkId": "maternal-11.1.4.1", "text": "Sistolik", "answer": [ { "valueQuantity": { "value": 130 } } ] }, { "linkId": "maternal-11.1.4.2", "text": "Diastolik", "answer": [ { "valueQuantity": { "value": 80 } } ] } ] }, { "linkId": "maternal-11.1.5", "text": "Denyutan Jantung Janin", "answer": [ { "valueQuantity": { "value": 110 } } ] }, { "linkId": "maternal-11.1.6", "text": "Urin Protein", "answer": [ { "valueQuantity": { "value": 3 } } ] } ] } ] } |
| 12. | Pemantauan Profil Pre-Eclampsia |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-12", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-12", "name": "QMaternal12", "title": "Pemantauan Profil Pre-Eclampsia", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "item": [ { "linkId": "maternal-12.1", "text": "Pemantauan Profil Pre-Eclampsia", "type": "group", "repeats": true, "item": [ { "linkId": "maternal-12.1.1", "text": "Tarikh", "type": "date" }, { "linkId": "maternal-12.1.2", "text": "POA/POG", "type": "quantity" }, { "linkId": "maternal-12.1.3", "text": "Tekanan Darah (BP)", "type": "group", "item": [ { "linkId": "maternal-12.1.3.1", "text": "Sistolik", "type": "quantity", "initial": [ { "valueQuantity": { "unit": "mmHg", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, { "linkId": "maternal-12.1.3.2", "text": "Diastolik", "type": "quantity", "initial": [ { "valueQuantity": { "unit": "mmHg", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] } ] }, { "linkId": "maternal-12.1.4", "text": "Proteinuria", "type": "choice", "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "167273002", "display": "Not Detected" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "167274008", "display": "Trace" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "167275009", "display": "1+" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "167276005", "display": "2+" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "167277001", "display": "3+" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "167278006", "display": "4+" } } ] }, { "linkId": "maternal-12.1.5", "text": "Urea", "type": "quantity", "initial": [ { "valueQuantity": { "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } } ] }, { "linkId": "maternal-12.1.6", "text": "Creatinine", "type": "quantity", "initial": [ { "valueQuantity": { "unit": "umol/L", "system": "http://unitsofmeasure.org", "code": "umol/L" } } ] }, { "linkId": "maternal-12.1.7", "text": "Uric Acid", "type": "quantity", "initial": [ { "valueQuantity": { "unit": "mmol/L", "system": "http://unitsofmeasure.org", "code": "mmol/L" } } ] }, { "linkId": "maternal-12.1.8", "text": "Hemoglobin", "type": "quantity", "initial": [ { "valueQuantity": { "unit": "g/dL", "system": "http://unitsofmeasure.org", "code": "g/dL" } } ] }, { "linkId": "maternal-12.1.9", "text": "Platelet", "type": "quantity", "initial": [ { "valueQuantity": { "unit": "10*3/uL", "system": "http://unitsofmeasure.org", "code": "10*3/uL" } } ] }, { "linkId": "maternal-12.1.10", "text": "AST", "type": "quantity", "initial": [ { "valueQuantity": { "unit": "IU/L", "system": "http://unitsofmeasure.org", "code": "[IU]/L" } } ] }, { "linkId": "maternal-12.1.11", "text": "ALT", "type": "quantity", "initial": [ { "valueQuantity": { "unit": "IU/L", "system": "http://unitsofmeasure.org", "code": "[IU]/L" } } ] }, { "linkId": "maternal-12.1.12", "text": "Nama Pemeriksa", "type": "string" }, { "linkId": "maternal-12.1.13", "text": "Masa", "type": "dateTime" } ] } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-12", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-12", "status": "completed", "subject": { "reference": "Patient/bfb81ffe-637d-4b3f-befa-f7a1546ed9f8" }, "authored": "2022-11-16T03:56:06.596Z", "item": [ { "linkId": "maternal-12.1", "text": "Pemantauan Profil Pre-Eclampsia", "item": [ { "linkId": "maternal-12.1.1", "text": "Tarikh", "answer": [ { "valueDate": "2023-02-22" } ] }, { "linkId": "maternal-12.1.2", "text": "POA/POG", "answer": [ { "valueQuantity": { "value": 2, "unit": "week", "system": "http://unitsofmeasure.org", "code": "wk" } } ] }, { "linkId": "maternal-12.1.3", "text": "Tekanan Darah (BP)", "item": [ { "linkId": "maternal-12.1.3.1", "text": "Sistolik", "answer": [ { "valueQuantity": { "value": 120, "unit": "mmHg", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] }, { "linkId": "maternal-12.1.3.2", "text": "Diastolik", "answer": [ { "valueQuantity": { "value": 80, "unit": "mmHg", "system": "http://unitsofmeasure.org", "code": "mm[Hg]" } } ] } ] }, { "linkId": "maternal-12.1.4", "text": "Proteinuria", "answer": [ { "valueQuantity": { "value": 150, "unit": "g/day", "system": "http://unitsofmeasure.org", "code": "g/d" } } ] }, { "linkId": "maternal-12.1.5", "text": "Urea", "answer": [ { "valueQuantity": { "value": 40, "unit": "g/mmol", "system": "http://unitsofmeasure.org", "code": "g/mmol" } } ] }, { "linkId": "maternal-12.1.6", "text": "Creatinine", "answer": [ { "valueQuantity": { "value": 4, "unit": "umol/L", "system": "http://unitsofmeasure.org", "code": "umol/L" } } ] }, { "linkId": "maternal-12.1.7", "text": "Uric Acid", "answer": [ { "valueQuantity": { "value": 3, "unit": "mg/dL", "system": "http://unitsofmeasure.org", "code": "mg/dL" } } ] }, { "linkId": "maternal-12.1.8", "text": "Hemoglobin", "answer": [ { "valueQuantity": { "value": 12, "unit": "g/dL", "system": "http://unitsofmeasure.org", "code": "g/dL" } } ] }, { "linkId": "maternal-12.1.9", "text": "Platelet", "answer": [ { "valueQuantity": { "value": 260, "unit": "10*3/uL", "system": "http://unitsofmeasure.org", "code": "10*3/uL" } } ] }, { "linkId": "maternal-12.1.10", "text": "AST", "answer": [ { "valueQuantity": { "value": 23, "unit": "U/L", "system": "http://unitsofmeasure.org", "code": "U/L" } } ] }, { "linkId": "maternal-12.1.11", "text": "ALT", "answer": [ { "valueQuantity": { "value": 23, "unit": "U/L", "system": "http://unitsofmeasure.org", "code": "U/L" } } ] }, { "linkId": "maternal-12.1.12", "text": "Nama Pemeriksa", "answer": [ { "valueString": "Jannah" } ] } ] } ] } |
| 13. | Pemantauan Peningkatan Berat Badan Ibu Antenatal |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-13", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-13", "version": "1.0.0", "name": "QMaternal13", "title": "Pemantauan Peningkatan Berat Badan Ibu Antenatal", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "item": [ { "linkId": "maternal-13.1", "text": "Tinggi", "type": "quantity" }, { "linkId": "maternal-13.2", "text": "Berat Ibu Sebelum Hamil", "type": "quantity" }, { "linkId": "maternal-13.3", "text": "Nilai BMI Sebelum Hamil", "type": "quantity" }, { "linkId": "maternal-13.4", "text": "Status BMI Sebelum Hamil", "type": "choice", "answerOption": [ { "valueCoding": { "code": "310252000", "display": "Kurang Berat Badan (BMI < 20)" } }, { "valueCoding": { "code": "35425004", "display": "Normal (BMI 20 -24)" } }, { "valueCoding": { "code": "162863004", "display": "Lebih Berat Badan (BMI 25 - 29)" } }, { "valueCoding": { "code": "162864005", "display": "Obese (BMI > 30)" } }, { "valueCoding": { "code": "408512008", "display": "Extreme Obese (BMI > 40)" } } ] }, { "linkId": "maternal-13.5", "text": "Jadual Berat Badan Sepanjang Kehamilan", "type": "group", "repeats": true, "item": [ { "linkId": "maternal-13.5.1", "text": "Tarikh Lawatan", "type": "dateTime" }, { "linkId": "maternal-13.5.2", "text": "Minggu Gestasi", "type": "quantity" }, { "linkId": "maternal-13.5.3", "text": "Berat Badan (kg)", "type": "quantity" }, { "linkId": "maternal-13.5.4", "text": "Peningkatan Berat Badan (kg)", "type": "quantity" }, { "linkId": "maternal-13.5.5", "text": "Kadar Peningkatan Berat Badan (kg)/ minggu", "type": "quantity" } ] } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-13", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-13", "status": "completed", "subject": { "reference": "Patient/bfb81ffe-637d-4b3f-befa-f7a1546ed9f8" }, "authored": "2022-11-16T03:56:06.596Z", "item": [ { "linkId": "maternal-13.1", "text": "Tinggi", "answer": [ { "valueQuantity": { "value": 165, "unit": "meter", "system": "http://unitsofmeasure.org", "code": "m" } } ] }, { "linkId": "maternal-13.2", "text": "Berat Ibu Sebelum Hamil", "answer": [ { "valueQuantity": { "value": 50, "unit": "kilogram", "system": "http://unitsofmeasure.org", "code": "kg" } } ] }, { "linkId": "maternal-13.3", "text": "Nilai BMI Sebelum Hamil", "answer": [ { "valueQuantity": { "value": 20, "unit": "kilogram per square meter", "system": "http://unitsofmeasure.org", "code": "kg/m2" } } ] }, { "linkId": "maternal-13.4", "text": "Status BMI Sebelum Hamil", "answer": [ { "valueCoding": { "code": "35425004", "display": "Normal (BMI 20 -24)" } } ] }, { "linkId": "maternal-13.5", "text": "Jadual Berat Badan Sepanjang Kehamilan", "item": [ { "linkId": "maternal-13.5.1", "text": "Tarikh Lawatan", "answer": [ { "valueDateTime": "2022-11-30T07:58:42.817Z" } ] }, { "linkId": "maternal-13.5.2", "text": "Minggu Gestasi", "answer": [ { "valueQuantity": { "value": 3 } } ] }, { "linkId": "maternal-13.5.3", "text": "Berat Badan (kg)", "answer": [ { "valueQuantity": { "value": 52, "unit": "kilogram", "system": "http://unitsofmeasure.org", "code": "kg" } } ] }, { "linkId": "maternal-13.5.4", "text": "Peningkatan Berat Badan (kg)", "answer": [ { "valueQuantity": { "value": 2, "unit": "kilogram", "system": "http://unitsofmeasure.org", "code": "kg" } } ] }, { "linkId": "maternal-13.5.5", "text": "Kadar Peningkatan Berat Badan (kg)/ minggu", "answer": [ { "valueQuantity": { "value": 2 } } ] } ] } ] } |
| 14. | Hb monitoring |
Store and displayed from Obstetric Hb (MY Core) record |
| 15. | Keputusan Pemeriksaan Ultrasound |
Store and displayed from Obstetric Us (MY Core) record |
| 16. | Fetal Growth Chart |
Store and displayed from Foetal Kick (MY Core) record |
| 17. | Sistem Kod Warna dan Senarai Semak Penjagaan Antenatal |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-17", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-17", "version": "1.0.0", "name": "QMaternal17", "title": "Sistem Kod Warna dan Senarai Semak Penjagaan Antenatal", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "description": "Sistem ini menggunakan empat kod warna. Penentuan kod warna ini adalah berdasarkan kepada penilaian faktor risiko ibu semasa lawatan ke klinik/ rumah", "purpose": "Penjagaan ibu adalah berdasarkan kepada kod warna berkenaan:-", "item": [ { "linkId": "maternal-17.0", "code": [ { "code": "maternal-17.0" } ], "text": "Trimester of Assessment", "type": "choice", "answerOption": [ { "valueCoding": { "code": "00", "display": "Trimester 1 (<12 weeks)" } }, { "valueCoding": { "code": "01", "display": "Trimester 2 (13-22 weeks)" } }, { "valueCoding": { "code": "02", "display": "Trimester 2 (23-27 weeks)" } }, { "valueCoding": { "code": "03", "display": "Trimester 3 (28-32 weeks)" } }, { "valueCoding": { "code": "04", "display": "Trimester 3 (33-36 weeks)" } }, { "valueCoding": { "code": "05", "display": "Trimester 3 (37-40 weeks)" } }, { "valueCoding": { "code": "06", "display": "Post-date (>40 weeks)" } } ] }, { "linkId": "maternal-17.2", "code": [ { "code": "maternal-17.2" } ], "text": "Rumusan", "type": "choice", "readOnly": true, "answerOption": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "386713009", "display": "Merah" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "371244009", "display": "Kuning" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "54662009", "display": "Hijau" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "371251000", "display": "Putih" } }, { "valueCoding": { "system": "http://snomed.info/sct", "code": "310586008", "display": "Putih (ABC)" } } ] }, { "linkId": "maternal-17.3", "code": [ { "code": "maternal-17.3" } ], "text": "Senarai Semak Pengendalian Ibu Hamil (Kod Merah)", "type": "group", "item": [ { "linkId": "maternal-17.3.1", "code": [ { "code": "maternal-17.1" } ], "text": "Eclampsia", "type": "boolean" }, { "linkId": "maternal-17.3.2", "code": [ { "code": "maternal-17.3.2" } ], "text": "Pre-eclampsia (tekanan darah tinggi dengan urin protein)", "type": "boolean" }, { "linkId": "maternal-17.3.3", "code": [ { "code": "maternal-17.3.3" } ], "text": "Hypertensive crisis", "type": "boolean" }, { "linkId": "maternal-17.3.4", "code": [ { "code": "maternal-17.3.4" } ], "text": "Penyakit jantung semasa mengandung, dengan tanda dan gejala (sesak nafas, berdebar-debar)", "type": "boolean" }, { "linkId": "maternal-17.3.5", "code": [ { "code": "maternal-17.3.5" } ], "text": "Sesak nafas dan/ atau kadar pernafasan >22/min", "type": "boolean" }, { "linkId": "maternal-17.3.6", "code": [ { "code": "maternal-17.3.6" } ], "text": "Pendarahan antepartum (termasuk keguguran)", "type": "boolean" }, { "linkId": "maternal-17.3.7", "code": [ { "code": "maternal-17.3.7" } ], "text": "Denyutan jantung janin yang abnormal \n • FHR <110/min selepas 22/52 \n • FHR >160/min selepas 32/52", "type": "boolean" }, { "linkId": "maternal-17.3.8", "code": [ { "code": "maternal-17.3.8" } ], "text": "Anemia dengan simptom pada mana-mana gestasi atau Hb ≤7g/dL", "type": "boolean" }, { "linkId": "maternal-17.3.9", "code": [ { "code": "maternal-17.3.9" } ], "text": "Kontraksi rahim pramatang", "type": "boolean" }, { "linkId": "maternal-17.3.10", "code": [ { "code": "maternal-17.3.10" } ], "text": "Keluar air ketuban tanpa kontraksi", "type": "boolean" }, { "linkId": "maternal-17.3.11", "code": [ { "code": "maternal-17.3.11" } ], "text": "Sawan", "type": "boolean" }, { "linkId": "maternal-17.3.12", "code": [ { "code": "maternal-17.3.12" } ], "text": "Demam dengan tanda-tanda sepsis (lesu, dehidrasi, tachycardia)", "type": "boolean" }, { "linkId": "maternal-17.3.13", "code": [ { "code": "maternal-17.3.13" } ], "text": "Kes disyaki denggi (demam berserta sakit kepala, sakit sendi, sakit perut, muntah, cirit birit dan sebagainya)", "type": "boolean" }, { "linkId": "maternal-17.3.14", "code": [ { "code": "maternal-17.3.14" } ], "text": "Gejala Deep Vein Thrombosis (DVT) dan/ atau Pulmonary Embolism", "type": "boolean" }, { "linkId": "maternal-17.3.15", "code": [ { "code": "maternal-17.3.15" } ], "text": "Keinginan mencederakan / bunuh diri", "type": "boolean" } ] }, { "linkId": "maternal-17.4", "code": [ { "code": "maternal-17.4" } ], "text": "Senarai Semak Pengendalian Ibu Hamil (Kod Kuning)", "type": "group", "item": [ { "linkId": "maternal-17.4.1", "code": [ { "code": "maternal-17.4.1" } ], "text": "Ibu HIV positif", "type": "boolean" }, { "linkId": "maternal-17.4.2", "code": [ { "code": "maternal-17.4.2" } ], "text": "Ibu Hepatitis B positif", "type": "boolean" }, { "linkId": "maternal-17.4.3", "code": [ { "code": "maternal-17.4.3" } ], "text": "Ibu Tuberkulosis/ Malaria/ Syphilis", "type": "boolean" }, { "linkId": "maternal-17.4.4", "code": [ { "code": "maternal-17.4.4" } ], "text": "Tekanan darah >140/90 - <160/100mmHg tanpa/dengan urin protein", "type": "boolean" }, { "linkId": "maternal-17.4.5", "code": [ { "code": "maternal-17.4.5" } ], "text": "Tekanan darah tinggi (140/90mmHg) dengan urin protein", "type": "boolean" }, { "linkId": "maternal-17.4.6", "code": [ { "code": "maternal-17.4.6" } ], "text": "Ibu diabetes dengan rawatan dan/ atau komplikasi", "type": "boolean" }, { "linkId": "maternal-17.4.7", "code": [ { "code": "maternal-17.4.7" } ], "text": "**Pergerakan janin kurang semasa kandungan ≥32 minggu dengan faktor risiko", "type": "boolean" }, { "linkId": "maternal-17.4.8", "code": [ { "code": "maternal-17.4.8" } ], "text": "Kandungan melebihi 7 hari dari EDD", "type": "boolean" }, { "linkId": "maternal-17.4.9", "code": [ { "code": "maternal-17.4.9" } ], "text": "Ibu dengan masalah perubatan yang memerlukan rawatan bersama di hospital", "type": "boolean" }, { "linkId": "maternal-17.4.10", "code": [ { "code": "maternal-17.4.10" } ], "text": "Ibu tunggal atau ibu remaja (<20 tahun)", "type": "boolean" }, { "linkId": "maternal-17.4.11", "code": [ { "code": "maternal-17.4.11" } ], "text": "Ibu berumur ≥40 tahun", "type": "boolean" }, { "linkId": "maternal-17.4.12", "code": [ { "code": "maternal-17.4.12" } ], "text": "Hemoglobin 7 - <9g/dL dan asymptomatic", "type": "boolean" }, { "linkId": "maternal-17.4.13", "code": [ { "code": "maternal-17.4.13" } ], "text": "Placenta previa tanpa pendarahan", "type": "boolean" }, { "linkId": "maternal-17.4.14", "code": [ { "code": "maternal-17.4.14" } ], "text": "Maternal pyrexia ≥38˚C atau >3 hari", "type": "boolean" }, { "linkId": "maternal-17.4.15", "code": [ { "code": "maternal-17.4.15" } ], "text": "Penyakit jantung tanpa gejala", "type": "boolean" }, { "linkId": "maternal-17.4.16", "code": [ { "code": "maternal-17.4.16" } ], "text": "*Ketagihan dadah/ rokok/ alkohol", "type": "boolean" }, { "linkId": "maternal-17.4.17", "code": [ { "code": "maternal-17.4.17" } ], "text": "Skor risiko antenatal Venous Thromboembolism (VTE) ≥3", "type": "boolean" }, { "linkId": "maternal-17.4.18", "code": [ { "code": "maternal-17.4.18" } ], "text": "Kandungan kembar", "type": "boolean" }, { "linkId": "maternal-17.4.19", "code": [ { "code": "maternal-17.4.19" } ], "text": "Masalah kesihatan mental", "type": "boolean" }, { "linkId": "maternal-17.4.20", "code": [ { "code": "maternal-17.4.20" } ], "text": "BMI >40kgm/2", "type": "boolean" } ] }, { "linkId": "maternal-17.5", "code": [ { "code": "maternal-17.5" } ], "text": "Senarai Semak Pengendalian Ibu Hamil (Kod Hijau)", "type": "group", "item": [ { "linkId": "maternal-17.5.1", "code": [ { "code": "maternal-17.5.1" } ], "text": "Rh negatif", "type": "boolean" }, { "linkId": "maternal-17.5.2", "code": [ { "code": "maternal-17.5.2" } ], "text": "Berat badan ibu sebelum mengandung atau ketika booking <45kg", "type": "boolean" }, { "linkId": "maternal-17.5.3", "code": [ { "code": "maternal-17.5.3" } ], "text": "Obes (≥30.0kg/m²)", "type": "boolean" }, { "linkId": "maternal-17.5.4", "code": [ { "code": "maternal-17.5.4" } ], "text": "Pertambahan berat badan yang mendadak (>2 kg dalam seminggu)", "type": "boolean" }, { "linkId": "maternal-17.5.5", "code": [ { "code": "maternal-17.5.5" } ], "text": "Berat badan statik atau menurun (dalam tempoh sebulan)", "type": "boolean" }, { "linkId": "maternal-17.5.6", "code": [ { "code": "maternal-17.5.6" } ], "text": "Masalah perubatan semasa", "type": "boolean" }, { "linkId": "maternal-17.5.7", "code": [ { "code": "maternal-17.5.7" } ], "text": "Masalah ginekologi yang lalu (fibroid, cyst, pembedahan)", "type": "boolean" }, { "linkId": "maternal-17.5.8", "code": [ { "code": "maternal-17.5.8" } ], "text": "LNMP yang tidak pasti", "type": "boolean" }, { "linkId": "maternal-17.5.9", "code": [ { "code": "maternal-17.5.9" } ], "text": "3 kali keguguran yang berturutan", "type": "boolean" }, { "linkId": "maternal-17.5.10", "code": [ { "code": "maternal-17.5.10" } ], "text": "Sejarah obstetrik yang lalu", "type": "group", "item": [ { "linkId": "maternal-17.5.10.1", "code": [ { "code": "maternal-17.5.10.1" } ], "text": "Pembedahan caesarean", "type": "boolean" }, { "linkId": "maternal-17.5.10.2", "code": [ { "code": "maternal-17.5.10.2" } ], "text": "PIH/ eclampsia/ diabetes", "type": "boolean" }, { "linkId": "maternal-17.5.10.3", "code": [ { "code": "maternal-17.5.10.3" } ], "text": "Kematian perinatal", "type": "boolean" }, { "linkId": "maternal-17.5.10.4", "code": [ { "code": "maternal-17.5.10.4" } ], "text": "Bayi dengan berat lahir <2.5kg atau >4kg", "type": "boolean" }, { "linkId": "maternal-17.5.10.5", "code": [ { "code": "maternal-17.5.10.5" } ], "text": "Luka perineum 3rd degree dan 4th degree", "type": "boolean" }, { "linkId": "maternal-17.5.10.6", "code": [ { "code": "maternal-17.5.10.6" } ], "text": "Retained placenta", "type": "boolean" }, { "linkId": "maternal-17.5.10.7", "code": [ { "code": "maternal-17.5.10.7" } ], "text": "Post partum haemorrhage", "type": "boolean" }, { "linkId": "maternal-17.5.10.8", "code": [ { "code": "maternal-17.5.10.8" } ], "text": "Kelahiran instrumental", "type": "boolean" } ] }, { "linkId": "maternal-17.5.11", "code": [ { "code": "maternal-17.5.11" } ], "text": "Pergerakan janin kurang semasa kandungan ≥32 minggu", "type": "boolean" }, { "linkId": "maternal-17.5.12", "code": [ { "code": "maternal-17.5.12" } ], "text": "Tekanan darah 140/90 mmHg tanpa urin protein", "type": "boolean" }, { "linkId": "maternal-17.5.13", "code": [ { "code": "maternal-17.5.13" } ], "text": "Hemoglobin 9 - <11g/dL", "type": "boolean" }, { "linkId": "maternal-17.5.14", "code": [ { "code": "maternal-17.5.14" } ], "text": "Glukosuria 2 kali", "type": "boolean" }, { "linkId": "maternal-17.5.15", "code": [ { "code": "maternal-17.5.15" } ], "text": "Air kencing mempunyai protein ≥1+", "type": "boolean" }, { "linkId": "maternal-17.5.16", "code": [ { "code": "maternal-17.5.16" } ], "text": "Tinggi rahim (SFH) tidak sejajar dengan jangkamasa kandungan +/- 3cm", "type": "boolean" }, { "linkId": "maternal-17.5.17", "code": [ { "code": "maternal-17.5.17" } ], "text": "Breech/ Oblique/ Tranverse dengan tiada tanda sakit bersalin pada 36 minggu kehamilan", "type": "boolean" }, { "linkId": "maternal-17.5.18", "code": [ { "code": "maternal-17.5.18" } ], "text": "Kepala bayi tinggi (Head not engaged) semasa kandungan 37 minggu bagi primigravida", "type": "boolean" }, { "linkId": "maternal-17.5.19", "code": [ { "code": "maternal-17.5.19" } ], "text": "Ibu GDM dengan kawalan diet tanpa komplikasi", "type": "boolean" }, { "linkId": "maternal-17.5.20", "code": [ { "code": "maternal-17.5.20" } ], "text": "Ibu berumur 36 - 39 tahun", "type": "boolean" }, { "linkId": "maternal-17.5.21", "code": [ { "code": "maternal-17.5.21" } ], "text": "Primigravida/pseudoprimigravida", "type": "boolean" }, { "linkId": "maternal-17.5.22", "code": [ { "code": "maternal-17.5.22" } ], "text": "Grandmultipara ≥5", "type": "boolean" }, { "linkId": "maternal-17.5.23", "code": [ { "code": "maternal-17.5.23" } ], "text": "Jarak kelahiran <2 tahun atau melebihi 5 tahun", "type": "boolean" }, { "linkId": "maternal-17.5.24", "code": [ { "code": "maternal-17.5.24" } ], "text": "Ketinggian ibu <145cm", "type": "boolean" } ] }, { "linkId": "maternal-17.6", "code": [ { "code": "maternal-17.6" } ], "text": "Senarai Semak Pengendalian Ibu Hamil (Kod Putih)", "type": "group", "enableWhen": [ { "question": "maternal-17.3", "operator": "exists", "answerBoolean": false }, { "question": "maternal-17.4", "operator": "exists", "answerBoolean": false }, { "question": "maternal-17.5", "operator": "exists", "answerBoolean": false } ], "enableBehavior": "all", "item": [ { "linkId": "maternal-17.6.1", "code": [ { "code": "maternal-17.6.1" } ], "text": "Gravida 2 – 5 (tidak termasuk pseudoprimigravida)", "type": "boolean" }, { "linkId": "maternal-17.6.2", "code": [ { "code": "maternal-17.6.2" } ], "text": "Tiada masalah obstetrik lalu dan semasa", "type": "boolean" }, { "linkId": "maternal-17.6.3", "code": [ { "code": "maternal-17.6.3" } ], "text": "Tiada masalah perubatan yang lalu dan semasa", "type": "boolean" }, { "linkId": "maternal-17.6.4", "code": [ { "code": "maternal-17.6.4" } ], "text": "Ibu berumur 20 - 35 tahun", "type": "boolean" }, { "linkId": "maternal-17.6.5", "code": [ { "code": "maternal-17.6.5" } ], "text": "Ibu berkahwin dan mempunyai sokongan keluarga", "type": "boolean" } ] }, { "linkId": "maternal-17.7", "code": [ { "code": "maternal-17.7" } ], "text": "Kriteria Untuk Bersalin Di ABC/ Rumah", "type": "group", "enableWhen": [ { "question": "maternal-17.6", "operator": "exists", "answerBoolean": true } ], "item": [ { "linkId": "maternal-17.7.1", "code": [ { "code": "maternal-17.7.1" } ], "text": "Gravida 2 – 5 (tidak termasuk pseudoprimigravida)", "type": "boolean" }, { "linkId": "maternal-17.7.2", "code": [ { "code": "maternal-17.7.2" } ], "text": "Tiada masalah obstetrik lalu dan semasa", "type": "boolean" }, { "linkId": "maternal-17.7.3", "code": [ { "code": "maternal-17.7.3" } ], "text": "Tiada masalah perubatan yang lalu dan semasa", "type": "boolean" }, { "linkId": "maternal-17.7.4", "code": [ { "code": "maternal-17.7.4" } ], "text": "Ibu berumur 20 - 35 tahun", "type": "boolean" }, { "linkId": "maternal-17.7.5", "code": [ { "code": "maternal-17.7.5" } ], "text": "Ibu berkahwin dan mempunyai sokongan keluarga", "type": "boolean" }, { "linkId": "maternal-17.7.6", "code": [ { "code": "maternal-17.7.6" } ], "text": "POA 37-40 minggu", "type": "boolean" }, { "linkId": "maternal-17.7.7", "code": [ { "code": "maternal-17.7.7" } ], "text": "Anggaran berat bayi 2.5-3.5kg", "type": "boolean" }, { "linkId": "maternal-17.7.8", "code": [ { "code": "maternal-17.7.8" } ], "text": "Persekitaran rumah ibu sesuai", "type": "boolean" } ] } ] } QuestionnaireResponse
{ "resourceType": "QuestionnaireResponse", "id": "qr-maternal-17", "meta": { "source": "http://provider.hie.moh.gov.my", "profile": [ "http://fhir.hie.moh.gov.my/StructureDefinition/QuestionnaireResponse-my-core" ] }, "questionnaire": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-17", "status": "completed", "subject": { "reference": "Patient/bfb81ffe-637d-4b3f-befa-f7a1546ed9f8" }, "authored": "2022-11-23T00:42:29.983Z", "item": [ { "linkId": "maternal-17.0", "text": "Trimester of Assessment", "answer": [ { "valueCoding": { "code": "00", "display": "Trimester 1 (<12 month)" } } ] }, { "linkId": "maternal-17.1", "text": "Jangkamasa tidak datang haid", "answer": [ { "valueString": "12/52" } ] }, { "linkId": "maternal-17.3", "text": "Senarai Semak Pengendalian Ibu Hamil (Kod Merah)", "item": [ { "linkId": "maternal-17.3.1", "text": "Eclampsia", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.2", "text": "Pre-eclampsia (tekanan darah tinggi dengan urin protein)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.3", "text": "Hypertensive crisis", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.4", "text": "Penyakit jantung semasa mengandung, dengan tanda dan gejala (sesak nafas, berdebar-debar)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.5", "text": "Sesak nafas dan/ atau kadar pernafasan >22/min", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.6", "text": "Pendarahan antepartum (termasuk keguguran)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.7", "text": "Denyutan jantung janin yang abnormal • FHR <110/min selepas 22/52 • FHR >160/min selepas 32/52", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.8", "text": "Anemia dengan simptom pada mana-mana gestasi atau Hb ≤7g/dL", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.9", "text": " Kontraksi rahim pramatang", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.10", "text": "Keluar air ketuban tanpa kontraksi", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.11", "text": " Sawan", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.12", "text": "Demam dengan tanda-tanda sepsis (lesu, dehidrasi, tachycardia)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.13", "text": "Kes disyaki denggi (demam berserta sakit kepala, sakit sendi, sakit perut, muntah, cirit birit dan sebagainya)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.14", "text": "Gejala Deep Vein Thrombosis (DVT) dan/ atau Pulmonary Embolism", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.3.15", "text": "Keinginan mencederakan / bunuh diri", "answer": [ { "valueBoolean": true } ] } ] }, { "linkId": "maternal-17.4", "text": "Senarai Semak Pengendalian Ibu Hamil (Kod Kuning)", "item": [ { "linkId": "maternal-17.4.1", "text": "Ibu HIV positif", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.2", "text": "Ibu Hepatitis B positif", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.3", "text": "Ibu Tuberkulosis/ Malaria/ Syphilis", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.4", "text": "Tekanan darah >140/90 - <160/100mmHg tanpa/dengan urin protein", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.5", "text": "Tekanan darah tinggi (140/90mmHg) dengan urin protein", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.6", "text": "Ibu diabetes dengan rawatan dan/ atau komplikasi", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.7", "text": "**Pergerakan janin kurang semasa kandungan ≥32 minggu dengan faktor risiko", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.8", "text": "Kandungan melebihi 7 hari dari EDD", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.9", "text": "Ibu dengan masalah perubatan yang memerlukan rawatan bersama di hospital", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.10", "text": "Ibu tunggal atau ibu remaja (<20 tahun)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.11", "text": "Ibu berumur ≥40 tahun", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.12", "text": "Hemoglobin 7 - <9g/dL dan asymptomatic", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.13", "text": "Placenta previa tanpa pendarahan", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.14", "text": "Maternal pyrexia ≥38˚C atau >3 hari", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.15", "text": "Penyakit jantung tanpa gejala", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.16", "text": "*Ketagihan dadah/ rokok/ alkohol", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.17", "text": "Skor risiko antenatal Venous Thromboembolism (VTE) ≥3", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.18", "text": "Kandungan kembar", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.19", "text": "Masalah kesihatan mental", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.4.20", "text": "BMI >40kgm/2", "answer": [ { "valueBoolean": true } ] } ] }, { "linkId": "maternal-17.5", "text": "Senarai Semak Pengendalian Ibu Hamil (Kod Hijau)", "item": [ { "linkId": "maternal-17.5.1", "text": "Rh negatif", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.5.2", "text": "Berat badan ibu sebelum mengandung atau ketika booking <45kg", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.5.3", "text": "Obes (≥30.0kg/m²)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.5.4", "text": "Pertambahan berat badan yang mendadak (>2 kg dalam seminggu)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.5.5", "text": "Berat badan statik atau menurun (dalam tempoh sebulan)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.5.6", "text": "Masalah perubatan semasa", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.5.7", "text": "Masalah ginekologi yang lalu (fibroid, cyst, pembedahan)", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.5.8", "text": "LNMP yang tidak pasti", "answer": [ { "valueBoolean": true } ] }, { "linkId": "maternal-17.5.9", "text": "3 kali keguguran yang berturutan", "answer": [ { "valueBoolean": true } ] } ] } ] } |
| 18. | Senarai Semak Risiko VTE Semasa Hamil dan Puerperium |
Questionnaire
{ "resourceType": "Questionnaire", "id": "q-maternal-18", "url": "http://fhir.hie.moh.gov.my/Questionnaire/q-maternal-18", "version": "1.0.0", "name": "QMaternal18", "title": "Senarai Semak Risiko VTE Semasa Hamil dan Puerperium", "status": "active", "date": "2024-02-12T04:04:09.5621857+00:00", "description": "Reference: Prevention & Treatment of Thromboembolism in Pregnancy and Puerperium, 2018", "purpose": "*Note: Thromboprophylaxis is recommended during the transient period. Consider stopping once the transient risks are deemed no longer significant.", "code": [ { "code": "q-maternal-18" } ], "item": [ { "linkId": "maternal-18.1", "code": [ { "code": "maternal-18.1" } ], "prefix": "1", "text": "VTE risk factor", "type": "choice", "answerOption": [ { "valueCoding": { "code": "00", "display": "Pre pregnancy/Booking" } }, { "valueCoding": { "code": "01", "display": "Admission New Illness" } }, { "valueCoding": { "code": "02", "display": "Post Delivery" } } ] }, { "linkId": "maternal-18.2", "code": [ { "code": "maternal-18.2" } ], "prefix": "2", "text": "Pre-existing risk factors", "type": "group", "item": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue-my-core", "valueDecimal": 4.0 } ], "linkId": "maternal-18.2.1", "code": [ { "code": "maternal-18.2.1" } ], "prefix": "2.1", "text": "Previous VTE (VTE Score - 4)", "type": "boolean" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue-my-core", "valueDecimal": 3.0 } ], "linkId": "maternal-18.2.2", "code": [ { "code": "maternal-18.2.2" } ], "prefix": "2.2", "text": "High risk thrombophilia (VTE Score - 3)", "type": "boolean" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue-my-core", "valueDecimal": 3.0 } ], "linkId": "maternal-18.2.3", "code": [ { "code": "maternal-18.2.3" } ], "prefix": "2.3", "text": "Medical comorbidities (VTE Score - 3)", "type": "boolean" }, { "linkId": "maternal-18.2.4", "code": [ { "code": "maternal-18.2.4" } ], "prefix": "2.4", "text": "Obesity", "type": "choice", "answerOption": [ { "valueCoding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue-my-core", "valueDecimal": 2.0 } ], "system": "http://fhir.hie.moh.gov.my/CodeSystem/maternal-record-my-core", "code": "00", "display": "BMI ≥40kg/m2 (VTE Score - 2)" } }, { "valueCoding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue-my-core", "valueDecimal": 1.0 } ], "system": "http://fhir.hie.moh.gov.my/CodeSystem/maternal-record-my-core"</ |