FHIR Implementation Guide for ABDM
7.0.0 - active
FHIR Implementation Guide for ABDM
7.0.0 - active
FHIR Implementation Guide for ABDM - Local Development build (v7.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Document Details
version: 1
Profile: INPS Bundle
Final Document at 2024-12-13 by Organization Fertility Clinic for ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
Document Subject
Profile: INPS Patient
ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
| Contact Detail |
| ||
Document Content
This patient is a pregnant woman in the antenatal phase, with pregnancy confirmed on 12-06-2024 and an estimated delivery date of 15-03-2025. She has moderate iron deficiency anaemia, and a urinary tract infection. Laboratory findings support these conditions, showing improving RBC levels and a confirmed E. coli infection. She is receiving appropriate treatment with prenatal vitamins, iron and folic acid supplements, and nitrofurantoin. Past conditions (appendicitis) are resolved, immunizations are up to date, and lifestyle factors are favorable. A mild allergy to prawns is noted. Overall, the patient is stable and under proper clinical management.
| Problem/Diagnosis | Severity | Status | Comment |
|---|---|---|---|
| Anaemia | Active | ||
| Urinary tract infection (UTI) | Moderate | Active | Patient reported symptoms of UTI. MSU to confirm |
| Type | Substance | Date/time of onset of first reaction | Manifestation | Severity of reaction | Comment |
|---|---|---|---|---|---|
| Allergy | Prawns | 18:50 02/11/2024 | Itchy throat | Mild | Pt stated had prawns with dinner and noticed itchy throat, never experienced this before |
| Medicine | Dose | Clinical Indication | Status | Last Updated | Comment |
|---|---|---|---|---|---|
| Prenatal vitamins | 1 tablet daily | Pregnancy | Active | 28/10/2024 | |
| Iron and Folic Acid | 2 tablets one in morning and evening | Anemia | Active | 04/11/2024 | |
| Nitrofurantoin | 100mg 6-hourly for 5 days | Urinary tract infection (UTI) | Active | 04/11/2024 |
| Vaccine | Date of administration | Comment |
|---|---|---|
| Diphtheria + tetanus + pertussis 5 component adolescent/adult vaccine injection, 0.5 mL syringe | 05/10/2024 | |
| Influenza vaccine | 05/05/2024 |
| Past Problem | Onset | Clinical Status | Verification Status | Severity |
|---|---|---|---|---|
| Appendicitis | November 11 2023 20:00 |
| Social History Observation | Value | Date | Status |
|---|---|---|---|
| Tobacco smoking status | Never smoker | Oct 19 2022 20:00 | final |
| Alcoholic drinks per day | 1 drink | Jun 21 2023 20:00 | final |
| Test Name | Test Result | Date |
|---|---|---|
| Urine M/C/S - pH | 7 | 05/11/2024 |
| Urine M/C/S - Protein | Positive | 05/11/2024 |
| Urine M/C/S - Blood | Positive | 05/11/2024 |
| Urine M/C/S - Glucose | Positive | 05/11/2024 |
| Urine M/C/S - Leucocytes | 370 x 10^6/L (<10) | 05/11/2024 |
| Urine M/C/S - Erythrocytes | 150 x 10^6/L (<10) | 05/11/2024 |
| Urine M/C/S - Epithelial cells | Nil | 05/11/2024 |
| Urine M/C/S - Culture | Org 1: Escherichia coli > 10^8 Organisms/mL | 05/11/2024 |
| Urine M/C/S - Antimicrobial susceptibility | Org 1 Amp/Amoxycillin: Susceptible Amox/clav. acid: Susceptible Cephalexin: Susceptible Trimethoprim: Susceptible Nitrofurantoin: Susceptible Gentamicin: Susceptible Norfloxacin: Susceptible | 05/11/2024 |
| Full Blood Count - Haemoglobin | 8 g/dL (12-16) | 12/06/2024 |
| Full Blood Count - Haematocrit | 0.37 L/L (0.37-0.51) | 12/06/2024 |
| Full Blood Count - White Blood Cell Count | 8 x 10^9/L (4.0-11.0) | 12/06/2024 |
| Full Blood Count - Platelets | 250 x 10^9/L (150-400) | 12/06/2024 |
| Full Blood Count - MCV | 85 fL (80-100) | 12/06/2024 |
| HCG | 16000 IU/L | 12/06/2024 |
| Vital Sign | Value | Date | Status |
|---|---|---|---|
| Body weight | 65 kg | Apr 10 2024 05:58 | final |
| Body mass index (BMI) [Ratio] | 24.56 kg/m2 | Apr 10 2024 05:58 | final |
| Blood pressure panel with all children optional | 140/80 mmHg | Aug 30 2024 04:32 | final |
Entry 2 - fullUrl = urn:uuid:d174bd1a-b368-41e6-83a2-af77f2b3c60f
Resource Patient:
Profile: INPS Patient
ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
Contact Detail
- ph: 0270108012(Home)
- ph: 0491571804(Mobile)
- 139 Jungle Lane Noida UP IN
Entry 3 - fullUrl = urn:uuid:7a17027f-acc0-4d77-bf84-c0dad8f7c881
Resource Organization:
Profile: INPS Organization
identifier: Provider number/4567878
type: Healthcare Provider
name: Fertility Clinic
Contacts
Telecom Address ph: 0255506323(Work) 158 Nagar Noida UP
Entry 4 - fullUrl = urn:uuid:8f8635dc-694e-408f-8ffe-1610d50f9823
Resource Organization:
Profile: INPS Organization
identifier: Provider number/4567879
type: Healthcare Provider
name: Fertility Clinic Chain
contact
telecom: ph: 0255506327(Work), info@fertility.clinic.chain.in
address: 81 Nagar Noida UP
Entry 5 - fullUrl = urn:uuid:94d12c8d-a3df-47a7-a0bb-0f29d64bafe2
Resource PractitionerRole:
Profile: INPS PractitionerRole
practitioner: Practitioner Dr. DEF
code: Doctor
Entry 6 - fullUrl = urn:uuid:816cf057-b736-4e08-baed-cc21e081b784
Resource Practitioner:
version: 1; Last updated: 2019-05-29 14:58:58+0530
Profile: INPS Practitioner
identifier: Medical License number/21-1521-3828-3227
name: Dr. DEF
Entry 7 - fullUrl = urn:uuid:9838cf73-c30d-4aa5-8ed8-36a079060b81
Resource AllergyIntolerance:
Profile: INPS AllergyTolerance
clinicalStatus: Active
verificationStatus: Unconfirmed
code: Prawns
patient: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
onset: 2024-11-02 18:50:00+1100
recordedDate: 2024-11-04
note:
Pt stated had prawns with dinner and noticed itchy throat, never experienced this before
Reactions
Manifestation Severity No display for AllergyIntolerance.reaction.manifestation (concept: ) Mild
Entry 8 - fullUrl = urn:uuid:8039e4a7-d459-454c-92a5-6c17ca2a824b
Resource Condition:
Profile: INPS Condition
clinicalStatus: Active
code: Anaemia
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
Entry 9 - fullUrl = urn:uuid:f8ab8ac1-56d1-4239-8303-dc70c1a3d0e1
Resource Condition:
Profile: INPS Condition
clinicalStatus: Active
verificationStatus: Confirmed
severity: Moderate
code: Urinary tract infection (UTI)
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
Entry 10 - fullUrl = urn:uuid:c3d31980-2a88-45b6-a7af-3fe8d32cc6fa
Resource MedicationStatement:
Profile: INPS MedicationStatement
status: stopped
status: recorded
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024 --> (ongoing)
dateAsserted: 2024-10-24
Dosages
Text 2 tablets one in morning and one in evening
Entry 11 - fullUrl = urn:uuid:b8dac343-16d7-49bf-ac36-b15e6726c343
Resource MedicationStatement:
Profile: INPS MedicationStatement
status: active
status: recorded
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024 --> (ongoing)
dateAsserted: 2024-10-24
Dosages
Text Route 1 tablet daily Oral route
Entry 12 - fullUrl = urn:uuid:b8e4d4a8-2c18-4f03-88dc-06f5f44f8058
Resource MedicationStatement:
Profile: INPS MedicationStatement
status: active
status: recorded
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-04 --> (ongoing)
dateAsserted: 2024-11-04
Dosages
Text Timing Route 100mg 6-hourly for 5 days Once per 6 hours Oral route
Entry 13 - fullUrl = urn:uuid:17b5a6d7-307b-4726-8c8c-0031e61582ce
Resource Immunization:
Profile: INPS Immunization
status: Completed
vaccineCode: Diphtheria + tetanus + pertussis 5 component adolescent/adult vaccine injection, 0.5 mL syringe
patient: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
occurrence: 2024-10-05
Performers
Actor Organization Fertility Clinic
Entry 14 - fullUrl = urn:uuid:14e8b0d8-b4e4-4f8e-b263-ef385787453b
Resource Immunization:
Profile: INPS Immunization
status: Completed
vaccineCode: Influenza Vaccine
patient: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
occurrence: 2024-07-05
Performers
Actor Organization Fertility Clinic
Entry 15 - fullUrl = urn:uuid:b0187efd-5f9b-474d-87bc-efebf877449a
Resource Observation:
status: Final
category: Laboratory
code: ABO group [Type] in Blood
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2023-10-31 15:06:00+0000
performer: PractitionerRole Clinical pathologist
value: Blood group A
Entry 16 - fullUrl = urn:uuid:f40b9e26-93b4-462b-8811-bdd6943873aa
Resource Observation:
status: Final
category: Laboratory
code: Urine M/C/S - pH
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: 7
Entry 17 - fullUrl = urn:uuid:612b7e6a-c902-45cb-b45c-d1894458a26b
Resource Observation:
status: Final
category: Laboratory
code: Urine M/C/S - Protein
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: Positive
Entry 18 - fullUrl = urn:uuid:15bd8c0c-fa53-4f5b-994b-487c7db3dc78
Resource Observation:
status: Final
category: Laboratory
code: Urine M/C/S - Blood
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: Positive
Entry 19 - fullUrl = urn:uuid:5019909f-097d-4a43-84d9-cc50143b8c82
Resource Observation:
status: Final
category: Laboratory
code: Urine M/C/S - Glucose
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: Positive
Entry 20 - fullUrl = urn:uuid:5d269392-79c1-4129-a142-0cdee6b49ea4
Resource Observation:
status: Final
category: Laboratory
code: Urine M/C/S - Leucocytes
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: 370 10*6/L (Details: UCUM code10*6/L = '10*6/L')
ReferenceRanges
Text <10
Entry 21 - fullUrl = urn:uuid:1eaafcef-7841-42c0-9e29-2fb1af2ca9b4
Resource Observation:
status: Final
category: Laboratory
code: Urine M/C/S - Erythrocytes
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: 150 10*6/L (Details: UCUM code10*6/L = '10*6/L')
ReferenceRanges
Text <10
Entry 22 - fullUrl = urn:uuid:ac0edca3-83cf-4291-8795-a07551f1ad9a
Resource Observation:
status: Final
category: Laboratory
code: Urine M/C/S - Culture
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: Escherichia coli
Entry 23 - fullUrl = urn:uuid:738cdcb5-679f-4491-8c30-f347735057d0
Resource Observation:
status: Final
category: Laboratory
code: Colony count
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: >100000000 /mL (Details: UCUM code/mL = '/mL')
Entry 24 - fullUrl = urn:uuid:92a88264-3979-4dcc-92df-47f4eaa9c4ce
Resource Observation:
status: Final
category: Laboratory
code: Amp/Amoxycillin
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: Susceptible
Entry 25 - fullUrl = urn:uuid:4e26d725-1f9b-4054-ae3f-e9053e31f68d
Resource Observation:
status: Final
category: Laboratory
code: Amox/clav. acid
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: Susceptible
Entry 26 - fullUrl = urn:uuid:e292aa91-87ab-4539-b854-9e889f7f3dea
Resource Observation:
status: Final
category: Laboratory
code: Cephalexin
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: Susceptible
Entry 27 - fullUrl = urn:uuid:98a8ec51-1547-4341-a1e0-c467e68ba5e3
Resource Observation:
status: Final
category: Laboratory
code: Trimethoprim
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: Susceptible
Entry 28 - fullUrl = urn:uuid:0aa8fc17-add4-48ae-bffb-5d27efbf55e2
Resource Observation:
status: Final
category: Laboratory
code: Nitrofurantoin
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: Susceptible
Entry 29 - fullUrl = urn:uuid:d0eda8ff-6fcd-44cc-8b46-342e4572fa60
Resource Observation:
status: Final
category: Laboratory
code: Gentamicin
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: Susceptible
Entry 30 - fullUrl = urn:uuid:a0e482c2-8642-4188-9d82-35aad634ef4f
Resource Observation:
status: Final
category: Laboratory
code: Norfloxacin
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-11-05
performer: PractitionerRole Clinical pathologist
value: Susceptible
Entry 31 - fullUrl = urn:uuid:86f47d61-0891-4bd2-ab89-08cb886bd06f
Resource Observation:
status: Final
category: Laboratory
code: Full Blood Count - Haemoglobin
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-06-12
performer: PractitionerRole Clinical pathologist
value: 8 g/dL (Details: UCUM codeg/dL = 'g/dL')
ReferenceRanges
Text 12-16
Entry 32 - fullUrl = urn:uuid:7e5288c6-f662-4d8d-86ec-dc1651997387
Resource Observation:
status: Final
category: Laboratory
code: Full Blood Count - Haematocrit
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-06-12
performer: PractitionerRole Clinical pathologist
value: 0.37 L/L (Details: UCUM codeL/L = 'L/L')
ReferenceRanges
Text 0.37-0.51
Entry 33 - fullUrl = urn:uuid:0b1e50b3-d39c-4acc-b08d-913f13c17974
Resource Observation:
status: Final
category: Laboratory
code: Full Blood Count - White Blood Cell Count
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-06-12
performer: PractitionerRole Clinical pathologist
value: 8 10*9/L (Details: UCUM code10*9/L = '10*9/L')
ReferenceRanges
Text 4.0-11.0
Entry 34 - fullUrl = urn:uuid:fae6e145-5fa6-44bd-9075-5176d72aff78
Resource Observation:
status: Final
category: Laboratory
code: Full Blood Count - Platelets
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-06-12
performer: PractitionerRole Clinical pathologist
value: 250 10*9/L (Details: UCUM code10*9/L = '10*9/L')
ReferenceRanges
Text 150-400
Entry 35 - fullUrl = urn:uuid:7bc34791-57e0-4ef6-b661-58f8e7a7e457
Resource Observation:
status: Final
category: Laboratory
code: Full Blood Count - MCV
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-06-12
performer: PractitionerRole Clinical pathologist
value: 85 fL (Details: UCUM codefL = 'fL')
ReferenceRanges
Text 80-100
Entry 36 - fullUrl = urn:uuid:36ff59b8-d5a7-438e-b8c6-cd54af10a4af
Resource Observation:
Profile: ObservationBodyWeight
status: Final
category: Vital Signs
code: Body weight
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-04-10 09:58:00+0000
performer: PractitionerRole Doctor
value: 143.3 lbs (Details: UCUM code[lb_av] = '[lb_av]')
Entry 37 - fullUrl = urn:uuid:96e33a60-dbd8-47ce-b613-be954243939e
Resource Observation:
Profile: ObservationBMI
status: Final
category: Vital Signs
code: Body mass index (BMI) [Ratio]
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-04-10 09:58:00+0000
performer: PractitionerRole Doctor
value: 24.56 kg/m2 (Details: UCUM codekg/m2 = 'kg/m2')
Entry 38 - fullUrl = urn:uuid:4ea539e1-fff9-4f56-964f-650d9e69ce58
Resource Observation:
Profile: ObservationBP
status: Final
category: Vital Signs
code: Blood pressure panel with all children optional
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-08-30 08:32:00+0000
performer: PractitionerRole Doctor
component
code: Systolic blood pressure
value: 85 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
interpretation: Normal
component
code: Diastolic blood pressure
value: 50 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
interpretation: Below low normal
Entry 39 - fullUrl = urn:uuid:9f906425-8c18-4580-ab30-61a56d7f4c05
Resource Observation:
Profile: INPS Observation Social Tobacco Use
status: Final
category: Social History
code: Tobacco smoking status
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2022-10-20
performer: PractitionerRole Doctor
value: Never smoker
Entry 40 - fullUrl = urn:uuid:e2e3f8aa-df2a-4357-b01f-a9fba6bb9b41
Resource Observation:
Profile: INPS Observation Social Alcohol Use
status: Final
category: Social History
code: Alcoholic drinks per day
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2016-06-22
performer: PractitionerRole Doctor
value: 1 d (Details: UCUM coded = 'd')
Entry 41 - fullUrl = urn:uuid:75ed6f24-9a7e-4568-9c05-91b6d4786743
Resource PractitionerRole:
Profile: INPS PractitionerRole
code: Clinical pathologist
Entry 42 - fullUrl = urn:uuid:77efacd9-b5a6-4b35-9764-269017ea7567
Resource Condition:
Profile: INPS Condition
clinicalStatus: Resolved
verificationStatus: Confirmed
code: Appendicitis
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
onset: 2023-11-25
Entry 43 - fullUrl = urn:uuid:f241ac65-5eab-49a0-8b92-7fb263274110
Resource Observation:
Profile: INPS Observation Pregnancy Status
status: Final
code: Pregnancy status
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-06-12
performer: Practitioner Dr. DEF
value: Pregnant
hasMember: Observation Delivery date Estimated
Entry 44 - fullUrl = urn:uuid:b29e71a6-6dd3-4f9d-bb21-2afb9e2b566c
Resource Observation:
status: Final
category: Imaging
code: Delivery date Estimated
subject: ABC Female, DoB: 1985-02-06 ( Medical record number: 22-7225-4829-5255)
effective: 2024-06-12
value: 2025-03-15