{ "resourceType": "Composition", "identifier": { "system": "http://sys-ids.kemkes.go.id/composition/{{Org_id}}", "value": "P20240001" }, "status": "final", "category": [ { "coding": [ { "system": "http://loinc.org", "code": "LP173421-1", "display": "Report" } ] } ], "type": { "coding": [ { "system": "http://loinc.org", "code": "88645-7", "display": "Outpatient hospital Discharge summary" } ] }, "subject": { "reference": "Patient/{{Patient_id}}" }, "date": "2023-06-04T10:24:47+00:00", "title": "Resume Medis Pasien Rawat Jalan {{Patient_Name}} pada tanggal 4 Juni 2023", "author": [ { "reference": "Practitioner/{{Practitioner_id}}" } ], "custodian": { "reference": "Organization/{{Org_id}}" }, "encounter": { "reference": "Encounter/{{Encounter_id}}" }, "section": [ { "title": "Anamnesis", "code": { "coding": [ { "system": "http://terminology.kemkes.go.id", "code": "TK000003", "display": "Anamnesis" } ] }, "section": [ { "title": "Keluhan Utama", "code": { "coding": [ { "system": 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"Tanda Vital", "code": { "coding": [ { "system": "http://loinc.org", "code": "8716-3", "display": "Vital signs" } ] }, "entry": [ { "reference": "Observation/{{Observation_TDSistolik}}" }, { "reference": "Observation/{{Observation_TDDiastolik}}" }, { "reference": "Observation/{{Observation_SuhuTubuh}}" }, { "reference": "Observation/{{Observation_DenyutJantung}}" }, { "reference": "Observation/{{Observation_Pernapasan}}" }, { "reference": "Observation/{{Observation_Kesadaran}}" }, { "reference": "Observation/{{Antrop_BB}}" }, { "reference": "Observation/{{Antrop_TB}}" }, { "reference": "Observation/{{Antrop_Luas}}" } ] }, { "title": "Pemeriksaan Fisik Head to Toe", "code": { "coding": [ { "system": "http://loinc.org", "code": "10187-3", "display": "Review of systems Narrative - Reported" } ] }, "entry": [ { "reference": "Observation/{{PemeriksaanFisik_Mata}}" }, { "reference": "Observation/{{PemeriksaanFisik_Telinga}}" } ] } ] }, { "title": "Pemeriksaan Fungsional", "code": { "coding": [ { "system": "http://loinc.org", "code": "47420-5", "display": "Functional status assessment note" } ] }, "entry": [ { "reference": "Observation/{{StatusPsikologis}}" } ] }, { "title": "Perencanaan Perawatan", "code": { "coding": [ { "system": "http://loinc.org", "code": "18776-5", "display": "Plan of care note" } ] }, "entry": [ { "reference": "ClinicalImpression/{{RiwayatPerjalananPenyakit}}" }, { "reference": "Goal/{{Goal_TujuanPerawatan}}" }, { "reference": "CarePlan/{{CarePlan_RencanaRawat}}" }, { "reference": "CarePlan/{{CarePlan_Instruksi}}" } ] }, { "title": "Pemeriksaan Penunjang", "code": { "coding": [ { "system": "http://terminology.kemkes.go.id", "code": "TK000009", "display": "Hasil Pemeriksaan Penunjang" } ] }, "section": [ { "title": "Hasil Pemeriksaan Laboratorium", "code": { "coding": [ { "system": "http://loinc.org", "code": "11502-2", "display": "Laboratory report" } ] }, "entry": [ { "reference": "ServiceRequest/{{ServiceRequest_Kuantitatif}}" }, { "reference": "Procedure/{{Procedure_StatusPuasa_Kuantitatif}}" }, { "reference": "Specimen/{{Specimen_Kuantitatif}}" }, { "reference": "Observation/{{Observation_Kuantitatif}}" }, { "reference": "DiagnosticReport/{{DiagnosticReport_Kuantitatif}}" } ] }, { "title": "Hasil Pemeriksaan Radiologi", "code": { "coding": [ { "system": "http://loinc.org", "code": "18782-3", "display": "Radiology Study observation (narrative)" } ] }, "entry": [ { "reference": "ServiceRequest/{{ServiceRequest_Rad}}" }, { "reference": "Procedure/{{Procedure_Rad}}" }, { "reference": "Observation/{{Observation_Rad1}}" }, { "reference": "AllergyIntolerance/{{AllergyIntolerance_Rad}}" }, { "reference": "ImagingStudy/{{ImagingStudy_id}}" }, { "reference": "Observation/{{Observation_Rad}}" }, { "reference": "DiagnosticReport/{{DiagnosticReport_Rad}}" } ] } ] }, { "title": "Diagnosis", "code": { "coding": [ { "system": "http://terminology.kemkes.go.id", "code": "TK000004", "display": "Diagnosis" } ] }, "section": [ { "title": "Diagnosis Akhir", "code": { "coding": [ { "system": "http://loinc.org", "code": "78375-3", "display": "Discharge diagnosis Narrative" } ] }, "entry": [ { "reference": "ClinicalImpression/{{Rasional_Klinis}}" }, { "reference": "Condition/{{Diagnosis_Primer}}" }, { "reference": "Condition/{{Diagnosis_Sekunder}}" }, { "reference": "RiskAssessment/{{Penilaian_Risiko}}" } ] } ] }, { "title": "Tindakan/Prosedur Medis", "code": { "coding": [ { "system": "http://terminology.kemkes.go.id", "code": "TK000005", "display": "Tindakan/Prosedur Medis" } ] }, "entry": [ { "reference": "Procedure/{{Procedure_EKG}}" }, { "reference": "Observation/{{Observation_EKG}}" }, { "reference": "Procedure/{{Procedure_Nebu}}" } ] }, { "title": "Farmasi", "code": { "coding": [ { "system": "http://terminology.kemkes.go.id", "code": "TK000013", "display": "Obat" } ] }, "section": [ { "title": "Obat Saat Kunjungan", "code": { "coding": [ { "system": "http://loinc.org", "code": "42346-7", "display": "Medications on admission (narrative)" } ] }, "entry": [ { "reference": "MedicationRequest/{{MedicationRequest_id2}}" }, { "reference": "MedicationDispense/{{MedicationDispense_id2}}" }, { "reference": "MedicationAdministration/{{MedicationAdministration_id2}}" } ] }, { "title": "Obat Pulang", "code": { "coding": [ { "system": "http://loinc.org", "code": "75311-1", "display": "Discharge medications Narrative" } ] }, "entry": [ { "reference": "MedicationRequest/{{MedicationRequest_id1}}" }, { "reference": "MedicationDispense/{{MedicationDispense_id1}}" } ] } ] }, { "title": "Diet", "section": [ { "title": "Rekomendasi Diet", "code": { "coding": [ { "system": "http://loinc.org", "code": "42344-2", "display": "Discharge diet (narrative)" } ] }, "entry": [ { "reference": "NutritionOrder/{{NutritionOrder_Diet}}" } ] } ] }, { "title": "Edukasi", "code": { "coding": [ { "system": "http://loinc.org", "code": "34895-3", "display": "Education note" } ] }, "entry": [ { "reference": "Procedure/{{Procedure_Edukasi}}" } ] }, { "title": "Kondisi Saat Meninggalkan Rumah Sakit", "code": { "coding": [ { "system": "http://loinc.org", "code": "10184-0", "display": "Hospital discharge physical findings Narrative" } ] }, "entry": [ { "reference": "ClinicalImpression/{{Prognosis_Pulang}}" }, { "reference": "Condition/{{KondisiMeninggalkanRS}}" } ] }, { "title": "Rencana Tindak Lanjut", "code": { "coding": [ { "system": "http://loinc.org", "code": "8653-8", "display": "Hospital Discharge instructions" } ] }, "entry": [ { "reference": "ServiceRequest/{{ServiceRequest_Kontrol}}" } ] }, { "title": "Perjalanan Kunjungan Pasien", "code": { "coding": [ { "system": "http://loinc.org", "code": "8648-8", "display": "Hospital course Narrative" } ] }, "text": { "status": "additional", "div": "Pasien {{Patient_Name}} masuk rumah sakit pada tanggal 4 Juni 2023 dengan keluhan utama yang sudah dirasakan selama 2 hari sebelum kunjungan. Selama anamnesis, pasien mengeluhkan selama 2 hari sebelum kunjungan. Riwayat penyakit terdahulu menunjukkan bahwa pasien sudah mengalami gejala selama 3 tahun dan tidak rutin berobat. Riwayat penyakit saat ini menunjukkan keluhan dimulai 2 hari sebelum kunjungan dengan intensitas sedang yang meningkat selama 2 jam terakhir. Pasien memiliki riwayat penyakit keluarga terkait keluhannya. Pasien juga memiliki riwayat alergi terhadap dan melaporkan mengonsumsi obat dua kali sehari selama 2 minggu terakhir. Hasil pemeriksaan fisik, menunjukkan hasil dalam batas normal. Pemeriksaan fungsional dan sosial juga dilakukan. Pasien kemudian menjalani pemeriksaan penunjang laboratorium dan radiologi. Pasien juga menjalani prosedur diagnostik dan terapetik. Pasien terkonfirmasi dengan {{DiagnosisKeluar}}. Pasien diberi obat pada saat saat kunjungan dan obat untuk dibawa pulang. Pasien pulang dengan prognosis baik dan keadaan stabil. Pasien direncanakan untuk melakukan kontrol kembali." } } ] }