The document describes the process of handling an outpatient visit case at a hospital using FHIR resources. It involves: 1) Creating an encounter record for the patient's visit with observations, procedures, and diagnoses added. 2) Updating the encounter record when the patient is discharged, including adding the discharge diagnosis. 3) Creating a discharge summary composition resource to educate the patient.

1. USE CASE TRAINING IHS
Resume Medis #2
Procedure, Observation, Composition
DIGITAL TRANSFORMATION OFFICE
KEMENTERIAN KESEHATAN
REPUBLIK INDONESIA

2. 3
Kasus 1
Seorang laki-laki berusia 37 tahun pada tanggal 14 Juni 2022 dengan NIK
3171022809990001 datang ke RS XXX ke poliklinik paru dengan dr.XXX Sp.P
dengan NIK 367400001111223.
Pasien dirujuk dari puskesmas dengan keluhan utama batuk lama dengan
keringat malam, dan sedikit sesak, hasil sputum BTA (+). Diketahui bahwa
pasien memiliki riwayat diabetes melitus tipe 2.
Hasil TTV :
- Tekanan Darah : 133/60 mmHg
- Laju Nafas : 22x/menit
- Nadi : 80x/menit
- Suhu : 38,8 C
Di RS, pasien menjalani pemeriksaan Rontgen dada.
Berdasarkan hasil pemeriksaan Rontgen dan sputum BTA, dokter spesialis paru
mendiagnosis pasien dengan diagnosis primer Tuberkulosis Paru terkonfirmasi
Bakteriologis. (A15.0) dan diagnosis sekunder Diabetes Melitus tipe 2 tanpa
komplikasi (E11.9)

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No Resource Action API Method Keterangan
1 Patient Get Patient IHS ID GET GET IHS-Number dari Master Patient Index by NIK
2 Practitioner Get Practitioner IHS ID GET GET IHS-Number dari Master Nakes Index by NIK
3 Organization - - Organisasi Induk / Suborganisasi
4 Location - - ID dari Poliklinik
Masterdata yang diperlukan
No Resource Action API Method Keterangan
1 Encounter - GET ID Encounter sebagai acuan dalam penyimpanan
Observation, Procedure, Composition
2 Condition - GET ID Condition sebagai salah satu data yang akan digunakan
untuk mengupdate (PUT) Encounter
Data Transaksional/Kunjungan yang diperlukan (Pre-requisite)

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No Resource Action API Method Keterangan
1 Encounter Membuat
encounter/kunjun
gan baru
POST Data elemen Encounter minimal yang perlu dikirim
● Encounter.identifier.use → official
● Encounter.identifier.system → http://sys-
ids.kemkes.go.id/encounter/{{organization-ihs-number}}
● Encounter.identifier.value → nomor registrasi kunjungan di
masing-masing RS
● Encounter.status → Arrived
● Encounter.statusHistory.status → Arrived
● Encounter.statusHistory.period.start → Jam kedatangan
(timeStamp with zone)
● Encounter.class.system →
http://terminology.hl7.org/CodeSystem/v3-ActCode
● Encounter.class.code → AMB
● Encounter.class.display → ambulatory
● Encounter.subject → Patient/IHS ID
● Encounter.participant.type.coding.system →
http://terminology.hl7.org/CodeSystem/participant-type
● Encounter.participant.type.coding.code → ATND
● Encounter.participant.type.coding.display → attender
● Encounter.participant.individual → Practitioner/IHS ID
● Encounter.period.start → Jam kedatangan
● Encounter.location.location → Location/No ID Location
● Encounter.serviceProvider → Organization/No ID Organization
Kunjungan Awal

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Kunjungan Awal

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No Resource Action API Method Keterangan
2 Observation Membuat
encounter/kunju
ngan baru
POST Data elemen Observation minimal yang perlu dikirim
● Observation.identifier.use → official
● Observation.identifier.system → http://sys-
ids.kemkes.go.id/observation/{{organization-ihs-number}}
● Observation.identifier.value → nomor ID hasil pemeriksaan yang
disimpan di masing-masing RS
● Observation.status → final
● Observation.category.coding.system →
http://terminology.hl7.org/CodeSystem/observation-category
● Observation.category.coding.code → vital-signs (Tanda vital)
● Observation.code→ Kode LOINC Pemeriksaan
(misalnya 8867-4 untuk Nadi)
● Observation.subject → Patient/IHS ID
● Observation.encounter → Referensi ID Encounter
● Observation.effectiveDateTime → Tanggal pemeriksaan dilakukan
● Observation.valueQuantity.value → angka (contoh : 120, 76, 80, 22)
● Observation.valueQuantity.unit → beats/minute ATAU mm[Hg] ATAU
C
● Observation.valueQuantity.system → http://unitsofmeasure.org
● Observation.valueQuantity.code → /min ATAU mm[Hg] ATAU Cel
● Observation.interpretation (Optional) → menjelaskan kondisi
http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation
Hasil Pemeriksaan
Tanda-tanda Vital &
Pemeriksaan Fisik
Bermakna

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Hasil Pemeriksaan
Tanda-tanda Vital &
Pemeriksaan Fisik
Bermakna

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3. Proses Pengiriman Data Tindakan/ Prosedur Medis
No Resource Action API Method Keterangan
3 Procedure Input data
prosedur/tindak
an medis
POST Data elemen Procedure minimal yang perlu dikirim
● Procedure.category : http://terminology.hl7.org/CodeSystem/condition-clinical → Kategori
prosedur
● Procedure.code : Kode tindakan ICD-9 CM (Contoh 87.44 Rontgen Thorax)
● Procedure.subject : Patient IHS Number
● Procedure.encounter : EncounterID
● Procedure.performedPeriod.start : waktu mulai tindakan
● Procedure.performedPeriod.end : waktu selesai tindakan
● Procedure.performer : Practitioner IHS Number
● Procedure.reasonCode : Kode diagnosis ICD-10 (Contoh : A15.0 Tuberculosis)
● Procedure.bodySite : Kode SNOMED CT untuk lokasi (Contoh : 302551006 Thorax)
● Procedure.note (opsional) : Keterangan tambahan

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3. Proses Pengiriman Data Tindakan/ Prosedur Medis

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No Resource Action API Method Keterangan
4 Condition Input data
diagnosis
POST Data elemen Condition minimal yang perlu dikirim
● Condition.clinicalStatus.coding.system →
http://terminology.hl7.org/CodeSystem/condition-clinical
● Condition.clinicalStatus.coding.code → active
● Condition.clinicalStatus.coding.display → Active
● Condition.category.coding.system → http://terminology.hl7.org/CodeSystem/condition-
category
● Condition.category.coding.code → encounter-diagnosis
● Condition.category.coding.display → Encounter Diagnosis
● Condition.code.coding.system → http://hl7.org/fhir/sid/icd-10
● Condition.code.coding.code → A15.0
● Condition.code.coding.display → Tuberculosis of lung, confirmed by sputum microscopy
with or without culture
● Condition.subject → Patient/IHS number pasien
● Condition.encounter → Encounter/No. ID Encounter
4. Proses pengiriman informasi Diagnosis

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4. Proses pengiriman informasi Diagnosis

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No Resource Action API Method Keterangan
5 Compositio
n
Input edukasi POST Data elemen Composition minimal yang perlu dikirim
● Composition.identifier.system → http://sys-ids.kemkes.go.id/encounter/{{organization-ihs-
number}}
● Composition.status → final
● Composition.type → LOINC code (Discharge Summary : 18842-5)
● Composition.category → LOINC code (Report : LP173421-1)
● Composition.subject → Patient/IHS number pasien
● Composition.encounter → Encounter/No. ID Encounter
● Composition.date → Tanggal notulen
● Composition.author → Practitioner ID
● Composition.title → Text (Resume Medis Rawat Jalan)
● Composition.custodian → OrganizationID
● Composition.section.code → LOINC Code (Discharge Diet : 42344-2)
● Composition.section.text.status → Additional
● Composition.section.text.div → text di dalam kontainer
(tidak boleh mengandung escape sequences seperti atau /)
5. Proses Edukasi Diet

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5. Proses Edukasi Diet

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No Resource Action API Method Keterangan
1 Encounte
r
● Update status
encounter menjadi
finished
● Input data
diagnosis pulang
PUT Data elemen Encounter minimal yang perlu dikirim
● id → id yang didapatkan dari POST encounter pertama kali
● Encounter.identifier.use → official
● Encounter.identifier.system → http://sys-
ids.kemkes.go.id/encounter/{{organization-ihs-number}}
● Encounter.identifier.value → nomor registrasi di masing-masing
RS
● Encounter.status → finished
● Encounter.statusHistory.status #1→ arrived
● Encounter.statusHistory.period.start #1 → Jam kedatangan
● Encounter.statusHistory.period.end #1 → Jam mulai dilakukan
asesmen awal
● Encounter.statusHistory.status #2→ in-progress
● Encounter.statusHistory.period.start #2 → Jam mulai dilakukan
asesmen awal
● Encounter.statusHistory.period.end #2 → Jam pasien pulang
● Encounter.statusHistory.status #3→ finished
● Encounter.statusHistory.period.start #3 → Jam pasien pulang
● Encounter.statusHistory.period.end #3 → Jam pasien pulang
● Encounter.class.system → http://terminology.hl7.org/CodeSystem/v3-
ActCode
● AMB
● Encounter.class.code → AMB
● Encounter.class.display → ambulatory
● Encounter.subject → Patient/IHS ID
6. Pasien Pulang

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No Resource Action API Method Keterangan
1 Encounte
r
● Update status
encounter menjadi
finished
● Input data
diagnosis pulang
PUT Data elemen Encounter minimal yang perlu dikirim (lanjutan)
● Encounter.participant.type.coding.system →
http://terminology.hl7.org/CodeSystem/participant-type
● Encounter.participant.type.coding.code → ATND
● Encounter.participant.type.coding.display → attender
● Encounter.participant.individual → Practitioner/IHS ID
● Encounter.diagnosis.condition → Condition/No. ID Condition
● Encounter.diagnosis.use.coding.system →
http://terminology.hl7.org/CodeSystem/diagnosis-role
● Encounter.diagnosis.use.coding.code → DD
● Encounter.diagnosis.use.coding.display → Discharge Diagnosis
● Encounter.period.start → Jam kedatangan
● Encounter.period.end → Jam pasien pulang
● Encounter.location.location → Location/No ID Location
● Encounter.serviceProvider → Organization/No ID Organization
6. Pasien Pulang

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6. Pasien Pulang