IosefaFuimaono-Bundle - FHIR New Zealand Patient Summary IG v0.7.0

FHIR New Zealand Patient Summary IG - Local Development build (v0.7.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Example Bundle: IosefaFuimaono-Bundle

Document Details

Profile: NZPS-Bundle

Final Document at 2023-11-26 09:37:18+1300 by Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000 for Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000

Document Subject

Profile: NZPS-Patient

Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, ))

Active:

true

Contact Detail

ph: 021111111(Mobile)
Brooklyn Street Claudelands Hamilton 3214 NZ (home)

Language:

Samoan

Next-of-kin:

Cindy Fuimaono
ph: 021111111(Mobile)

Links:

General Practitioner: Dr James Test-Smith

Patient Birth Place

Samoa

NZ Ethnicity

Samoan

Document Content

Medications

Losartan potassium 50 mg tablet – 1 tablet daily (oral)
Insulin glargine (Lantus) 100 IU/mL – 20 units per day (injection)
Dulaglutide 1.5 mg/0.5 mL – 1 injection weekly
Metformin – twice daily
Amlodipine 5 mg tablet – 1 tablet daily (oral)
Aspirin 75 mg – 1 tablet daily (oral)
Allopurinol 300 mg tablet – 1 tablet nightly (oral)

Allergies and Intolerances

Diazepam – confirmed allergy. Experienced increased confusion and headaches when prescribed for anxiety and difficulty sleeping.

Problems

Fracture of neck of femur (left hip) – onset June 2019
Type 2 diabetes mellitus – onset February 2011, on insulin
Gout – onset March 2015
Benign essential hypertension (mild) – onset October 2012

Immunizations

Influenza (Flu 65+) – June 2015
Pneumococcal PCV13 High Risk – July 2015
Influenza (Flu 65+) – June 2019
Tdap adult – June 2019
COVID-19 Comirnaty dose 1 – July 2021
COVID-19 Comirnaty dose 2 – August 2022

Results

Results from 5 March 2023:

HbA1c: 60 mmol/mol
LDL cholesterol: 3.4 mmol/L
Total cholesterol: 5.1 mmol/L
HDL cholesterol: 1.5 mmol/L

Vital Signs

Most recent readings (25 November 2023):

Blood pressure: 136/88 mmHg
Heart rate: 84 bpm
Height: 1.84 m
Weight: 104 kg (29 September 2023)

Past Problems

Primary open reduction and internal fixation of left proximal femoral fracture – June 2019. Concussion symptoms ongoing following fall.

Functional Status

Uses a walking frame or electric scooter. Often confused, struggles to communicate in English. Relies on caregiver Cindy for assistance with many activities of daily living. Does not leave the house much. Family arranging transfer to residential care.

Patient Story

Iosefa is a 73-year-old Samoan man who speaks Samoan as his primary language. He lives in Hamilton and relies heavily on his next of kin Cindy Fuimaono. He uses a walking frame or electric scooter to get around and rarely leaves the home. Family is in the process of arranging a transfer to residential care.

Plan of Care

No active plan of care recorded.

Social History

Ex-smoker. Was smoking 30 packs per year, quit in 2005 (1-9 cigarettes/day, light smoker).

Advance Directives

No advance directives recorded.

Additional Resources Included in Document

Entry 2 - fullUrl = urn:uuid:036f662687f7d30f8204d43dc9f48d3f

Resource Patient:

Profile: NZPS-Patient
Iosefa Fuimaono (official) Male, DoB: 1950-07-04 ( https://standards.digital.health.nz/ns/nhi-id#NHI#ZZZ0016 (use: official, ))
Active: true
Contact Detail
ph: 021111111(Mobile)
Brooklyn Street Claudelands Hamilton 3214 NZ (home)
Language: Samoan
Next-of-kin:
Cindy Fuimaono
ph: 021111111(Mobile)
Links:
General Practitioner: Dr James Test-Smith
Patient Birth Place Samoa
NZ Ethnicity Samoan

Entry 3 - fullUrl = urn:uuid:33c4a7626b35b4ceb5fd1cc32b5f93df

Resource Practitioner:

Profile: NZPS-Practitioner
active: true
name: James Test-Smith

Entry 4 - fullUrl = urn:uuid:9953dad2925ab4f7fa3a2eff5fa5fc25

Resource PractitionerRole:

Profile: NZPS-PractitionerRole
practitioner: Dr James Test-Smith
organization: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
code: Enrolled GP

Entry 5 - fullUrl = urn:uuid:fab8a5ac1c4e5706198e1b493950fb74

Resource Organization:

Profile: https://fhir-ig.digital.health.nz/nzps/StructureDefinition/nzps-organization
identifier: HPIFacility/F99820-C (use: official, )
active: true
name: Training Database

Entry 6 - fullUrl = urn:uuid:48ca96b1b18156892219d1677da61311

Resource Condition:

Profile: NZPS-Problem (Condition)
Long Term Condition Indicator: true
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
code: Fracture of neck of femur
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
onset: 2019-06-08
recordedDate: 2023-11-26 09:58:31+1300
note:
Left hip fracture

Entry 7 - fullUrl = urn:uuid:02fbdd1b0da8ba4eefc444cf486250c4

Resource Condition:

Profile: NZPS-Problem (Condition)
Long Term Condition Indicator: true
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
code: Type 2 diabetes mellitus
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
onset: 2011-02-05
recordedDate: 2023-11-26 10:02:45+1300
note:
On insulin

Entry 8 - fullUrl = urn:uuid:74b42c9b1f42eaf8e85bb36a5658fb41

Resource Condition:

Profile: NZPS-Problem (Condition)
Long Term Condition Indicator: true
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
code: Gout
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
onset: 2015-03-18
recordedDate: 2023-11-26 10:05:13+1300

Entry 9 - fullUrl = urn:uuid:b7d026c435307a67da16b541c27394dd

Resource Condition:

Profile: NZPS-Problem (Condition)
Long Term Condition Indicator: true
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
severity: Mild
code: Benign essential hypertension
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
onset: 2012-10-24
recordedDate: 2023-11-26 10:07:25+1300

Entry 10 - fullUrl = urn:uuid:b0aea1cbb4d9f62301f116b8b6e6ffc5

Resource Condition:

Profile: NZPS-Problem (Condition)
Long Term Condition Indicator: true
clinicalStatus: Resolved
verificationStatus: Confirmed
category: Problem List Item
code: Primary open reduction and internal fixation of proximal femoral fracture
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
onset: 2019-06-08
recordedDate: 2023-11-26 10:24:06+1300
note:
Left femur fracture. Concussion symptoms still ongoing following fall in 2019.

Entry 11 - fullUrl = urn:uuid:1a8dffadb213ef5b67b37b1644801e69

Resource Condition:

Profile: NZPS-Problem (Condition)
Long Term Condition Indicator: true
clinicalStatus: Active
verificationStatus: Confirmed
category: Problem List Item
code: Walking aid use
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
onset: 2019-06-30
recordedDate: 2023-11-26 10:29:07+1300
note:
Uses a walker or scooter

Entry 12 - fullUrl = urn:uuid:5253154ae81536f2d40c111d7bbfb8e9

Resource MedicationStatement:

Profile: NZPS-MedicationStatement
NZePS Long Term Medication Indicator: true
status: active
status: recorded
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
dateAsserted: 2023-11-25
informationSource: Dr James Test-Smith
Dosages
- Text Route
* 1 tablet daily Oral route

Entry 13 - fullUrl = urn:uuid:9ca9432b46c084cad83347dbcf464820

Resource MedicationStatement:

Profile: NZPS-MedicationStatement
NZePS Long Term Medication Indicator: true
status: active
status: recorded
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
dateAsserted: 2023-11-25
informationSource: Dr James Test-Smith
Dosages
- Text Route
* 20 units per day Subcutaneous route

Entry 14 - fullUrl = urn:uuid:88423fa47cc3b84d83d02e9094c200cb

Resource MedicationStatement:

Profile: NZPS-MedicationStatement
NZePS Long Term Medication Indicator: true
status: active
status: recorded
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
dateAsserted: 2023-11-25
informationSource: Dr James Test-Smith
Dosages
- Text Route
* 1 injection every week Subcutaneous route

Entry 15 - fullUrl = urn:uuid:2ef824b7138563c6223d8b1a5187af3a

Resource MedicationStatement:

Profile: NZPS-MedicationStatement
NZePS Long Term Medication Indicator: true
status: active
status: recorded
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
dateAsserted: 2023-11-25
informationSource: Dr James Test-Smith
Dosages
- Text Route
* Twice daily – 1 in morning and 1 at night Oral route

Entry 16 - fullUrl = urn:uuid:ecdae4372aa167d1380def606d69c7e5

Resource MedicationStatement:

Profile: NZPS-MedicationStatement
NZePS Long Term Medication Indicator: true
status: active
status: recorded
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
dateAsserted: 2023-11-25
informationSource: Dr James Test-Smith
Dosages
- Text Route
* 1 tablet daily Oral route

Entry 17 - fullUrl = urn:uuid:8bd8c9ba09ab3681ba54e7e03fb0b403

Resource MedicationStatement:

Profile: NZPS-MedicationStatement
NZePS Long Term Medication Indicator: true
status: active
status: recorded
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
dateAsserted: 2023-11-25
informationSource: Dr James Test-Smith
Dosages
- Text Route
* 1 tablet daily – 75 mg Oral route

Entry 18 - fullUrl = urn:uuid:62549ba6c27b5d0afdbeef3b7f77803c

Resource MedicationStatement:

Profile: NZPS-MedicationStatement
NZePS Long Term Medication Indicator: true
status: active
status: recorded
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
dateAsserted: 2023-11-25
informationSource: Dr James Test-Smith
Dosages
- Text Route
* 1 tablet nightly Oral route

Entry 19 - fullUrl = urn:uuid:2f2747acd1288279ac39e2a09ebd0e57

Resource AllergyIntolerance:

Profile: NZPS-AllergyIntolerance
clinicalStatus: Active
verificationStatus: Confirmed
code: Diazepam
patient: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
onset: 2023-11-26
recordedDate: 2023-11-26 10:34:09+1300
note:
Prescribed diazepam for anxiety and difficulty sleeping. Experienced increased confusion and headaches, which went away after stopping the drug.

Entry 20 - fullUrl = urn:uuid:7b634530b7b02f838a53008070506508

Resource Immunization:

Profile: NZPS-Immunization
status: Completed
vaccineCode: Influenza
lotNumber: P9076556
patient: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
occurrence: 2015-06-01
site: Left Arm
route: Injection, intramuscular
Performers
- Function Actor
* Administering Provider Dr James Test-Smith

Entry 21 - fullUrl = urn:uuid:2eb5ee1650806e5c9f5d9cca2bc353fd

Resource Immunization:

Profile: NZPS-Immunization
status: Completed
vaccineCode: Pneumococcal conjugate vaccine, 13 valent
lotNumber: U456789
patient: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
occurrence: 2015-07-01
site: Right Arm
route: Injection, intramuscular
Performers
- Function Actor
* Administering Provider Dr James Test-Smith

Entry 22 - fullUrl = urn:uuid:07b9d9377576d4a893205190d66ae17c

Resource Immunization:

Profile: NZPS-Immunization
status: Completed
vaccineCode: Influenza
lotNumber: Y789T75
patient: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
occurrence: 2019-06-01
site: Left Arm
route: Injection, intramuscular
Performers
- Function Actor
* Administering Provider Dr James Test-Smith

Entry 23 - fullUrl = urn:uuid:ab27e21761f52344df7c954f54afb3cc

Resource Immunization:

Profile: NZPS-Immunization
status: Completed
vaccineCode: Diphtheria adult dosage, Tetanus, acellular Pertussis
lotNumber: 12345
patient: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
occurrence: 2019-06-08
site: Left Arm
route: Injection, intramuscular
Performers
- Function Actor
* Administering Provider Dr James Test-Smith

Entry 24 - fullUrl = urn:uuid:6aaa45c30aab6f5da7c7f13a2fa035e0

Resource Immunization:

Profile: NZPS-Immunization
status: Completed
vaccineCode: COVID-19 Comirnaty (Pfizer/BioNTech)
lotNumber: 2907888
patient: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
occurrence: 2021-07-14
site: Left Arm
route: Injection, intramuscular
Performers
- Function Actor
* Administering Provider Dr James Test-Smith
note:
Dose 1

Entry 25 - fullUrl = urn:uuid:65da648ba7a1d796c72e5a2af8747945

Resource Immunization:

Profile: NZPS-Immunization
status: Completed
vaccineCode: COVID-19 Comirnaty (Pfizer/BioNTech)
lotNumber: 56789
patient: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
occurrence: 2022-08-04
site: Right Arm
route: Injection, intramuscular
Performers
- Function Actor
* Administering Provider Dr James Test-Smith
note:
Dose 2

Entry 26 - fullUrl = urn:uuid:273b1118abd62a58ea39de94dec2254c

Resource Observation:

Profile: NZPS-Observation-Results-Laboratory-Pathology
status: Final
category: Laboratory
code: HbA1c
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
effective: 2023-03-05 10:46:20+1300
performer: Dr James Test-Smith
value: 60 mmol/mol (Details: UCUM codemmol/mol = 'mmol/mol')

Entry 27 - fullUrl = urn:uuid:e5092ac2a96575423d0c24a34467530d

Resource Observation:

Profile: NZPS-Observation-Results-Laboratory-Pathology
status: Final
category: Laboratory
code: LDL cholesterol
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
effective: 2023-03-05 10:46:24+1300
performer: Dr James Test-Smith
value: 3.4 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

Entry 28 - fullUrl = urn:uuid:e7e97c3f132a641f0f1fd15701d24073

Resource Observation:

Profile: NZPS-Observation-Results-Laboratory-Pathology
status: Final
category: Laboratory
code: Total cholesterol
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
effective: 2023-03-05 10:46:26+1300
performer: Dr James Test-Smith
value: 5.1 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

Entry 29 - fullUrl = urn:uuid:b4f44ff5e0e630804b846e61933df15e

Resource Observation:

Profile: NZPS-Observation-Results-Laboratory-Pathology
status: Final
category: Laboratory
code: HDL cholesterol
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
effective: 2023-03-05 10:46:27+1300
performer: Dr James Test-Smith
value: 1.5 mmol/L (Details: UCUM codemmol/L = 'mmol/L')

Entry 30 - fullUrl = urn:uuid:020731df5eea5c0eaf4a600985814d39

Resource Observation:

Profiles: NZPS-Observation-Vital-Signs, Observation Blood Pressure Profile
status: Final
category: Vital Signs
code: Blood pressure
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
effective: 2023-11-25 14:20:33+1300
performer: Dr James Test-Smith
component
code: Systolic blood pressure
value: 136 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')
component
code: Diastolic blood pressure
value: 88 mmHg (Details: UCUM codemm[Hg] = 'mm[Hg]')

Entry 31 - fullUrl = urn:uuid:1b8c11ab07360666a849008d5c383760

Resource Observation:

Profiles: NZPS-Observation-Vital-Signs, Observation Heart Rate Profile
status: Final
category: Vital Signs
code: Heart rate
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
effective: 2023-11-25 14:20:11+1300
performer: Dr James Test-Smith
value: 84 beats/minute (Details: UCUM code/min = '/min')

Entry 32 - fullUrl = urn:uuid:68aa862c7d803fb339c1dab856053940

Resource Observation:

Profiles: NZPS-Observation-Vital-Signs, Observation Body Height Profile
status: Final
category: Vital Signs
code: Body height
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
effective: 2023-11-25 14:21:02+1300
performer: Dr James Test-Smith
value: 184 cm (Details: UCUM codecm = 'cm')

Entry 33 - fullUrl = urn:uuid:3ec9fa7e620474cddb8928cc3096dbaf

Resource Observation:

Profiles: NZPS-Observation-Vital-Signs, Observation Body Weight Profile
status: Final
category: Vital Signs
code: Body weight
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
effective: 2023-09-29
performer: Dr James Test-Smith
value: 104 kg (Details: UCUM codekg = 'kg')

Entry 34 - fullUrl = urn:uuid:06b2cb39d2f19ff8c2e1080d8e9e199e

Resource Observation:

Profile: NZPS-Observation-Smoking-Status
status: Final
category: Social History
code: Tobacco smoking status
subject: Bundle: identifier = UUID:79c87f51-3fcc-437e-ad12-2ad2b95b2321; type = document; timestamp = 2023-11-26 09:37:19+0000
effective: 2023-11-26
performer: Dr James Test-Smith
value: Ex-smoker
note:
Was smoking 30 packs per year, quit in 2005. Previously 1-9 cigarettes per day (light smoker).