<confidentiality value="N" /> <custodian> <reference value="Organization/11-05060009" /> </custodian> <event> <code> <coding> <system value="http://loinc.org" /> <code value="64285-0" /> <display value="Medical history screening form" /> </coding> </code> <period> <start value="2024-07-18T08:00:00+08:00" /> </period> </event> <section> <code> <coding> <system value="http://loinc.org" /> <code value="11450-4" /> <display value="Problem list" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tbody> <tr> <th>Status</th> <th>Name</th> <th>Category</th> <th>Onset</th> <th>Abatement</th> </tr> <tr> <td>active</td> <td>Pneumonia</td> <td>Encounter Diagnosis</td> <td>2024-07-01</td> <td>2024-07-17</td> </tr> <tr> <td>active</td> <td> <div> <div>Essential hypertension</div> </div> </td> <td>Comorbidities</td> <td>N/A</td> <td>N/A</td> </tr> <tr> <td>active</td> <td> <div> <div>Type 2 diabetes mellitus</div> </div> </td> <td>Comorbidities</td> <td>N/A</td> <td>N/A</td> </tr> </tbody> </table> </div> </text> <entry> <reference value="Condition/ca211a37-a7b9-42f7-a853-70cbb2f8f295" /> </entry> <entry> <reference value="Condition/3051480c-2a46-4818-b4dc-57de6159e3d8" /> </entry> <entry> <reference value="Condition/bb5460e7-cf4e-4799-8724-07f531dfa984" /> </entry> </section> <section> <code> <coding> <system value="http://loinc.org" /> <code value="8716-3" /> <display value="Vital Signs" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tbody> <tr> <th>Parameter</th> <th>Value</th> <th>Unit</th> </tr> <tr> <td>Respiratory Rate</td> <td>16</td> <td>/bpm</td> </tr> <tr> <td>Oxygen Saturation</td> <td>94</td> <td>%</td> </tr> <tr> <td>Heart Rate</td> <td>60</td> <td>/bpm</td> </tr> <tr> <td>Systolic Blood Pressure</td> <td>80</td> <td>mmHg</td> </tr> <tr> <td>Diastolic Blood Pressure</td> <td>60</td> <td>mmHg</td> </tr> <tr> <td>Temperature</td> <td> <div> <div>31</div> </div> </td> <td>'C</td> </tr> <tr> <td>Pain Score</td> <td>8</td> </tr> </tbody> </table> </div> </text> <entry> <reference value="Observation/urn:uuid:00000011-0001-0001-0003-000000000001" /> </entry> </section> <section> <code> <coding> <system value="http://loinc.org" /> <code value="55418-8" /> <display value="Anthropometry" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tbody> <tr> <th>Parameter</th> <th>Value</th> <th>Unit</th> </tr> <tr> <td>Height</td> <td>168</td> <td>cm</td> </tr> <tr> <td>Weight</td> <td>55</td> <td>kg</td> </tr> <tr> <td>BMI</td> <td>19.5</td> <td> <div> <div>kg/m2</div> </div> </td> </tr> <tr> <td>Waist Circumference</td> <td>28</td> <td>cm</td> </tr> </tbody> </table> </div> </text> <entry> <reference value="Observation/urn:uuid:00000011-0001-0001-0004-000000000001" /> </entry> </section> <section> <code> <coding> <system value="http://loinc.org" /> <code value="72166-2" /> <display value="Smoking History" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tbody> <tr> <td>Smoking Status</td> <td>true</td> </tr> <tr> <td>Lifetime smoking use</td> <td>15 years</td> </tr> <tr> <td>Date quit smoking</td> <td>19/7/2024</td> </tr> </tbody> <tfoot> <tr> <td>Smoking device</td> <td>Cigarette</td> </tr> <tr> <td>Smoking history</td> <td>Patient has been smoking for the past 15 years, have plan to quit now</td> </tr> </tfoot> </table> </div> </text> <entry> <reference value="Observation/f1ac639e-052f-4d2f-a7dc-ebb6eb0334f2" /> </entry> </section> <section> <code> <coding> <system value="http://loinc.org" /> <code value="74013-4" /> <display value="Alcohol Use History" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"> <p> <b>Authored Date</b>: 19-Jul-2024</p> <p> <b>Author</b>: SAIFULDAULAH BIN MOHD HAFIZ NGOO</p> <blockquote> <b>Please select your gender</b>: male<br /><br /><b>How often do you have a drink containing alcohol?</b>: Monthly or less<br /><br /><b>How many standard drinks containing alcohol do you have on a typical day when drinking?</b>: 3 or 4<br /><br /><b>How often do you have six or more drinks on one occasion?</b>: Less than monthly<br /><br /><b>During the past year, how often have you found that you were not able to stop drinking once you had started?</b>: Less than monthly<br /><br /><b>During the past year, how often have you failed to do what was normally expected of you because of drinking?</b>: Weekly<br /><br /><b>During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?</b>: Weekly<br /><br /><b>During the past year, how often have you had a feeling of guilt or remorse after drinking?</b>: Monthly<br /><br /><b>During the past year, how often have you been unable to remember what happened the night before because you had been drinking?</b>: Monthly<br /><br /><b>Have you or someone else been injured as a result of your drinking?</b>: Yes, during the past year<br /><br /><b>Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?</b>: Yes, but not in the past year<br /><br /><b>Total score [AUDIT]</b>: 20<br /><b>Outcome Summary [AUDIT]</b>: Likelihood of alcohol dependence (moderate-severe alcohol use disorder)<br /></blockquote> </div> </text> <entry> <reference value="QuestionnaireResponse/e2fd5c67-c11d-4300-a113-8880116aba18" /> </entry> </section> <section> <code> <coding> <system value="http://loinc.org" /> <code value="30954-2" /> <display value="Lab diagnostic Report" /> </coding> </code> <text> <status value="generated" /> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tbody> <tr> <th>Performed</th> <th>Test</th> <th>Conclusion</th> </tr> <tr> <td> <div> <div>2024-07-01T12:25:35+08:00</div> </div> </td> <td> <div> <div>Hemoglobin A1c/Hemoglobin.total (HbA1c)</div> </div> </td> <td>7.2%</td> </tr> </tbody> </table> </div> </text> <entry> <reference value="DiagnosticReport/urn:uuid:00000111-0001-0001-0003-000000000001" /> </entry> </section> </Composition>


  
    
      
      
      
    
  
  
    
  
  
    
  
  
  
    
    
  
  
  <confidentiality value="N" />
  <custodian>
    <reference value="Organization/11-05060009" />
  </custodian>
  <event>
    <code>
      <coding>
        <system value="http://loinc.org" />
        <code value="64285-0" />
        <display value="Medical history screening form" />
      </coding>
    </code>
    <period>
      <start value="2024-07-18T08:00:00+08:00" />
    </period>
  </event>
  <section>
    <code>
      <coding>
        <system value="http://loinc.org" />
        <code value="11450-4" />
        <display value="Problem list" />
      </coding>
    </code>
    <text>
      <status value="generated" />
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tbody>
            <tr>
              <th>Status</th>
              <th>Name</th>
              <th>Category</th>
              <th>Onset</th>
              <th>Abatement</th>
            </tr>
            <tr>
              <td>active</td>
              <td>Pneumonia</td>
              <td>Encounter Diagnosis</td>
              <td>2024-07-01</td>
              <td>2024-07-17</td>
            </tr>
            <tr>
              <td>active</td>
              <td>
                <div>
                  <div>Essential hypertension</div>
                </div>
              </td>
              <td>Comorbidities</td>
              <td>N/A</td>
              <td>N/A</td>
            </tr>
            <tr>
              <td>active</td>
              <td>
                <div>
                  <div>Type 2 diabetes mellitus</div>
                </div>
              </td>
              <td>Comorbidities</td>
              <td>N/A</td>
              <td>N/A</td>
            </tr>
          </tbody>
        </table>
      </div>
    </text>
    <entry>
      <reference value="Condition/ca211a37-a7b9-42f7-a853-70cbb2f8f295" />
    </entry>
    <entry>
      <reference value="Condition/3051480c-2a46-4818-b4dc-57de6159e3d8" />
    </entry>
    <entry>
      <reference value="Condition/bb5460e7-cf4e-4799-8724-07f531dfa984" />
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="http://loinc.org" />
        <code value="8716-3" />
        <display value="Vital Signs" />
      </coding>
    </code>
    <text>
      <status value="generated" />
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tbody>
            <tr>
              <th>Parameter</th>
              <th>Value</th>
              <th>Unit</th>
            </tr>
            <tr>
              <td>Respiratory Rate</td>
              <td>16</td>
              <td>/bpm</td>
            </tr>
            <tr>
              <td>Oxygen Saturation</td>
              <td>94</td>
              <td>%</td>
            </tr>
            <tr>
              <td>Heart Rate</td>
              <td>60</td>
              <td>/bpm</td>
            </tr>
            <tr>
              <td>Systolic Blood Pressure</td>
              <td>80</td>
              <td>mmHg</td>
            </tr>
            <tr>
              <td>Diastolic Blood Pressure</td>
              <td>60</td>
              <td>mmHg</td>
            </tr>
            <tr>
              <td>Temperature</td>
              <td>
                <div>
                  <div>31</div>
                </div>
              </td>
              <td>'C</td>
            </tr>
            <tr>
              <td>Pain Score</td>
              <td>8</td>
            </tr>
          </tbody>
        </table>
      </div>
    </text>
    <entry>
      <reference value="Observation/urn:uuid:00000011-0001-0001-0003-000000000001" />
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="http://loinc.org" />
        <code value="55418-8" />
        <display value="Anthropometry" />
      </coding>
    </code>
    <text>
      <status value="generated" />
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tbody>
            <tr>
              <th>Parameter</th>
              <th>Value</th>
              <th>Unit</th>
            </tr>
            <tr>
              <td>Height</td>
              <td>168</td>
              <td>cm</td>
            </tr>
            <tr>
              <td>Weight</td>
              <td>55</td>
              <td>kg</td>
            </tr>
            <tr>
              <td>BMI</td>
              <td>19.5</td>
              <td>
                <div>
                  <div>kg/m2</div>
                </div>
              </td>
            </tr>
            <tr>
              <td>Waist Circumference</td>
              <td>28</td>
              <td>cm</td>
            </tr>
          </tbody>
        </table>
      </div>
    </text>
    <entry>
      <reference value="Observation/urn:uuid:00000011-0001-0001-0004-000000000001" />
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="http://loinc.org" />
        <code value="72166-2" />
        <display value="Smoking History" />
      </coding>
    </code>
    <text>
      <status value="generated" />
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tbody>
            <tr>
              <td>Smoking Status</td>
              <td>true</td>
            </tr>
            <tr>
              <td>Lifetime smoking use</td>
              <td>15 years</td>
            </tr>
            <tr>
              <td>Date quit smoking</td>
              <td>19/7/2024</td>
            </tr>
          </tbody>
          <tfoot>
            <tr>
              <td>Smoking device</td>
              <td>Cigarette</td>
            </tr>
            <tr>
              <td>Smoking history</td>
              <td>Patient has been smoking for the past 15 years, have plan to quit now</td>
            </tr>
          </tfoot>
        </table>
      </div>
    </text>
    <entry>
      <reference value="Observation/f1ac639e-052f-4d2f-a7dc-ebb6eb0334f2" />
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="http://loinc.org" />
        <code value="74013-4" />
        <display value="Alcohol Use History" />
      </coding>
    </code>
    <text>
      <status value="generated" />
      <div xmlns="http://www.w3.org/1999/xhtml">
        <p>
          <b>Authored Date</b>: 19-Jul-2024</p>
        <p>
          <b>Author</b>: SAIFULDAULAH BIN MOHD HAFIZ NGOO</p>
        <blockquote>
          <b>Please select your gender</b>: male<br /><br /><b>How often do you have a drink containing alcohol?</b>: Monthly or less<br /><br /><b>How many standard drinks containing alcohol do you have on a typical day when drinking?</b>: 3 or 4<br /><br /><b>How often do you have six or more drinks on one occasion?</b>: Less than monthly<br /><br /><b>During the past year, how often have you found that you were not able to stop drinking once you had started?</b>: Less than monthly<br /><br /><b>During the past year, how often have you failed to do what was normally expected of you because of drinking?</b>: Weekly<br /><br /><b>During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?</b>: Weekly<br /><br /><b>During the past year, how often have you had a feeling of guilt or remorse after drinking?</b>: Monthly<br /><br /><b>During the past year, how often have you been unable to remember what happened the night before because you had been drinking?</b>: Monthly<br /><br /><b>Have you or someone else been injured as a result of your drinking?</b>: Yes, during the past year<br /><br /><b>Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?</b>: Yes, but not in the past year<br /><br /><b>Total score [AUDIT]</b>: 20<br /><b>Outcome Summary [AUDIT]</b>: Likelihood of alcohol dependence (moderate-severe alcohol use disorder)<br /></blockquote>
      </div>
    </text>
    <entry>
      <reference value="QuestionnaireResponse/e2fd5c67-c11d-4300-a113-8880116aba18" />
    </entry>
  </section>
  <section>
    <code>
      <coding>
        <system value="http://loinc.org" />
        <code value="30954-2" />
        <display value="Lab diagnostic Report" />
      </coding>
    </code>
    <text>
      <status value="generated" />
      <div xmlns="http://www.w3.org/1999/xhtml">
        <table>
          <tbody>
            <tr>
              <th>Performed</th>
              <th>Test</th>
              <th>Conclusion</th>
            </tr>
            <tr>
              <td>
                <div>
                  <div>2024-07-01T12:25:35+08:00</div>
                </div>
              </td>
              <td>
                <div>
                  <div>Hemoglobin A1c/Hemoglobin.total (HbA1c)</div>
                </div>
              </td>
              <td>7.2%</td>
            </tr>
          </tbody>
        </table>
      </div>
    </text>
    <entry>
      <reference value="DiagnosticReport/urn:uuid:00000111-0001-0001-0003-000000000001" />
    </entry>
  </section>
</Composition>