{ "resourceType" : "Bundle", "id" : "ClaimsForm4", "identifier" : { "system" : "http://nhdr.gov.ph/fhir/ValueSet-form-type", "value" : "CF4" }, "type" : "transaction", "entry" : [{ "fullUrl" : "urn:uuid:patient", "resource" : { "resourceType" : "Patient", "id" : "CF4-Patient", "meta" : { "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Patient"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: Patient CF4-Patient

Profile: PH Patient

John Mark Apilyido (no stated gender), DoB Unknown ( PhilHealth ID:\u00a0PH-00001)

Sex at birthM
" }, "extension" : [{ "url" : "https://nhdr.gov.ph/fhir/StructureDefinition/Sex", "valueCode" : "M" }], "identifier" : [{ "type" : { "text" : "PhilHealth ID" }, "system" : "http://nhdr.gov.ph/fhir/Identifier/philhealth-id", "value" : "PH-00001" }], "name" : [{ "family" : "Apilyido", "given" : ["John", "Mark"], "suffix" : ["Mr."] }] }, "request" : { "method" : "POST", "url" : "Patient" } }, { "fullUrl" : "urn:uuid:organization", "resource" : { "resourceType" : "Organization", "id" : "CF4-Organization", "meta" : { "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Organization"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: Organization CF4-Organization

Profile: PH Organization

identifier: PhilHealth Accreditation Number (PAN)/AN199513893

name: 6th General Hospital

address: 572 BLK 2 LOT 21 Maharlika Village 2300

" }, "identifier" : [{ "type" : { "coding" : [{ "code" : "AN" }], "text" : "PhilHealth Accreditation Number (PAN)" }, "value" : "AN199513893" }], "name" : "6th General Hospital", "address" : [{ "extension" : [{ "url" : "https://nhdr.gov.ph/fhir/StructureDefinition/Barangay", "valueCoding" : { "code" : "036916001", "display" : "San Roque" } }, { "url" : "https://nhdr.gov.ph/fhir/StructureDefinition/CityMunicipality", "valueCoding" : { "code" : "036916000", "display" : "Tarlac City" } }, { "url" : "https://nhdr.gov.ph/fhir/StructureDefinition/Province", "valueCoding" : { "code" : "036900000", "display" : "Tarlac" } }], "line" : ["572 BLK 2 LOT 21", "Maharlika Village"], "postalCode" : "2300" }] }, "request" : { "method" : "POST", "url" : "Organization" } }, { "fullUrl" : "urn:uuid:encounter", "resource" : { "resourceType" : "Encounter", "id" : "CF4-Encounter", "meta" : { "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Encounter"] }, "text" : { "status" : "extensions", "div" : "

Generated Narrative: Encounter CF4-Encounter

Profile: PH Encounter

Age in Years: 35

status: Finished

class: ActCode: AMB (Ambulatory)

period: 2026-03-11 08:00:00+0800 --> 2026-03-11 09:30:00+0800

reasonReference: Observation

Hospitalizations

-DischargeDisposition
*Discharged to home
" }, "extension" : [{ "url" : "https://nhdr.gov.ph/fhir/StructureDefinition/AgeYears", "valueInteger" : 35 }], "status" : "finished", "class" : { "system" : "http://terminology.hl7.org/CodeSystem/v3-ActCode", "code" : "AMB", "display" : "Ambulatory" }, "period" : { "start" : "2026-03-11T08:00:00+08:00", "end" : "2026-03-11T09:30:00+08:00" }, "reasonReference" : [{ "reference" : "Observation/CF4-Observation-Pertinent-Past-Medical-History", "display" : "Observation" }], "hospitalization" : { "dischargeDisposition" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/discharge-disposition", "code" : "home", "display" : "Discharged to home" }] } } }, "request" : { "method" : "POST", "url" : "Encounter" } }, { "fullUrl" : "urn:uuid:condition", "resource" : { "resourceType" : "Condition", "id" : "CF4-Condition", "meta" : { "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Condition"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: Condition CF4-Condition

Profile: PH Condition

code: Essential (primary) hypertension

subject: Patient

note: ,

Patient reports persistent headaches for the past 2 weeks.

\n

Past medical history includes type 2 diabetes mellitus, controlled on metformin.

\n
" }, "code" : { "coding" : [{ "system" : "http://hl7.org/fhir/sid/icd-10", "code" : "I10", "display" : "Essential (primary) hypertension" }] }, "subject" : { "reference" : "Patient/CF4-Patient", "display" : "Patient" }, "note" : [{ "text" : "Patient reports persistent headaches for the past 2 weeks." }, { "text" : "Past medical history includes type 2 diabetes mellitus, controlled on metformin." }] }, "request" : { "method" : "POST", "url" : "Condition" } }, { "fullUrl" : "urn:uuid:observation", "resource" : { "resourceType" : "Observation", "id" : "CF4-Observation-Pertinent-Past-Medical-History", "meta" : { "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Observation"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: Observation CF4-Observation-Pertinent-Past-Medical-History

Profile: PH Observation

status: Final

code: Pregnancy history panel

dataAbsentReason: Not Applicable

component

code: OB/GYN History (G)

value: 3

component

code: OB/GYN History (P)

value: 2

component

code: OB/GYN History (P)(T)

value: 1

component

code: OB/GYN History (P)(P)

value: 1

component

code: OB/GYN History (P)(A)

value: 0

component

code: OB/GYN History (P)(L)

value: 2

component

code: OB/GYN History - LMP

value: 2026-02-01

" }, "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "57075-4", "display" : "Pregnancy history panel" }] }, "dataAbsentReason" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/data-absent-reason", "code" : "not-applicable" }] }, "component" : [{ "code" : { "text" : "OB/GYN History (G)" }, "valueInteger" : 3 }, { "code" : { "text" : "OB/GYN History (P)" }, "valueInteger" : 2 }, { "code" : { "text" : "OB/GYN History (P)(T)" }, "valueInteger" : 1 }, { "code" : { "text" : "OB/GYN History (P)(P)" }, "valueInteger" : 1 }, { "code" : { "text" : "OB/GYN History (P)(A)" }, "valueInteger" : 0 }, { "code" : { "text" : "OB/GYN History (P)(L)" }, "valueInteger" : 2 }, { "code" : { "text" : "OB/GYN History - LMP" }, "valueDateTime" : "2026-02-01" }] }, "request" : { "method" : "POST", "url" : "Observation" } }, { "fullUrl" : "urn:uuid:observation", "resource" : { "resourceType" : "Observation", "id" : "CF4-Observation-Pertinent-Signs-and-Symptoms-on-Admission", "meta" : { "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Observation"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: Observation CF4-Observation-Pertinent-Signs-and-Symptoms-on-Admission

Profile: PH Observation

status: Final

code: Pertinent signs and symptoms on admission

component

code: Altered mental sensorium

value: true

component

code: Abdominal cramp/pain

value: true

component

code: Anorexia

value: false

component

code: Bleeding gum

value: false

component

code: Body weakness

value: true

" }, "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "75325-1", "display" : "Pertinent signs and symptoms on admission" }] }, "component" : [{ "code" : { "text" : "Altered mental sensorium" }, "valueBoolean" : true }, { "code" : { "text" : "Abdominal cramp/pain" }, "valueBoolean" : true }, { "code" : { "text" : "Anorexia" }, "valueBoolean" : false }, { "code" : { "text" : "Bleeding gum" }, "valueBoolean" : false }, { "code" : { "text" : "Body weakness" }, "valueBoolean" : true }] }, "request" : { "method" : "POST", "url" : "Observation" } }, { "fullUrl" : "urn:uuid:observation", "resource" : { "resourceType" : "Observation", "id" : "CF4-Observation-Physical-Examination-on-Admission", "meta" : { "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Observation"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: Observation CF4-Observation-Physical-Examination-on-Admission

Profile: PH Observation

status: Final

code: Physical findings on admission

component

code: Body height

value: 160 cm

component

code: Body weight

value: 65 kg

component

code: Mental status - level of consciousness

value: Awake and alert

component

code: Blood pressure panel

value: 120/80 mmHg

component

code: Heart rate

value: 82 beats/min

component

code: Respiratory rate

value: 20 breaths/min

component

code: Body temperature

value: 37 °C

component

code: HEENT

value: Essentially Normal

component

code: Chest/Lungs

value: Symmetrical chest expansion

component

code: CVS

value: Displaced apex beat

component

code: Abdomen

value: Abdominal rigidity

component

code: GU (IE)

value: Blood stained on examining finger

component

code: Skin/Extremities

value: Rashes/petechiae

component

code: Neuro Exam

value: Essentially normal

" }, "status" : "final", "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "29545-1", "display" : "Physical findings on admission" }] }, "component" : [{ "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "8302-2", "display" : "Body height" }] }, "valueQuantity" : { "value" : 160, "unit" : "cm" } }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "29463-7", "display" : "Body weight" }] }, "valueQuantity" : { "value" : 65, "unit" : "kg" } }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "80313-0", "display" : "Mental status - level of consciousness" }] }, "valueString" : "Awake and alert" }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "85354-9", "display" : "Blood pressure panel" }] }, "valueString" : "120/80 mmHg" }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "8867-4", "display" : "Heart rate" }] }, "valueQuantity" : { "value" : 82, "unit" : "beats/min" } }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "9279-1", "display" : "Respiratory rate" }] }, "valueQuantity" : { "value" : 20, "unit" : "breaths/min" } }, { "code" : { "coding" : [{ "system" : "http://loinc.org", "code" : "8310-5", "display" : "Body temperature" }] }, "valueQuantity" : { "value" : 37, "unit" : "°C" } }, { "code" : { "text" : "HEENT" }, "valueString" : "Essentially Normal" }, { "code" : { "text" : "Chest/Lungs" }, "valueString" : "Symmetrical chest expansion" }, { "code" : { "text" : "CVS" }, "valueString" : "Displaced apex beat" }, { "code" : { "text" : "Abdomen" }, "valueString" : "Abdominal rigidity" }, { "code" : { "text" : "GU (IE)" }, "valueString" : "Blood stained on examining finger" }, { "code" : { "text" : "Skin/Extremities" }, "valueString" : "Rashes/petechiae" }, { "code" : { "text" : "Neuro Exam" }, "valueString" : "Essentially normal" }] }, "request" : { "method" : "POST", "url" : "Observation" } }, { "fullUrl" : "urn:uuid:servicerequest", "resource" : { "resourceType" : "ServiceRequest", "id" : "CF4-ServiceRequest", "meta" : { "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-ServiceRequest"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: ServiceRequest CF4-ServiceRequest

Profile: PH ServiceRequest

status: Completed

intent: Order

subject: Patient

requester: Organization

reasonReference: Observation

" }, "status" : "completed", "intent" : "order", "subject" : { "reference" : "Patient/CF4-Patient", "display" : "Patient" }, "requester" : { "reference" : "Organization/CF4-Organization", "display" : "Organization" }, "reasonReference" : [{ "reference" : "Observation/CF4-Observation-Physical-Examination-on-Admission", "display" : "Observation" }] }, "request" : { "method" : "POST", "url" : "ServiceRequest" } }, { "fullUrl" : "urn:uuid:clinicalimpression", "resource" : { "resourceType" : "ClinicalImpression", "id" : "CF4-ClinicalImpression", "meta" : { "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-ClinicalImpression"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: ClinicalImpression CF4-ClinicalImpression

Profile: PH ClinicalImpression

status: Completed

description: Clinical impression on admission based on history, pertinent signs and symptoms, and physical examination.

subject: Patient

effective: 2026-03-12 09:30:00+0800

" }, "status" : "completed", "description" : "Clinical impression on admission based on history, pertinent signs and symptoms, and physical examination.", "subject" : { "reference" : "Patient/CF4-Patient", "display" : "Patient" }, "effectiveDateTime" : "2026-03-12T09:30:00+08:00" }, "request" : { "method" : "POST", "url" : "ClinicalImpression" } }, { "fullUrl" : "urn:uuid:provenance", "resource" : { "resourceType" : "Provenance", "id" : "CF4-Provenance", "meta" : { "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Provenance"] }, "text" : { "status" : "generated", "div" : "

Generated Narrative: Provenance CF4-Provenance

Profile: PH Provenance

Provenance for Claim

Summary

Recorded2026-02-03 09:00:00+0800

Agents

who
Practitioner
" }, "target" : [{ "reference" : "Claim/CF4-Claim", "display" : "Claim" }], "recorded" : "2026-02-03T09:00:00+08:00", "agent" : [{ "who" : { "reference" : "Practitioner/K4-Practitioner", "display" : "Practitioner" } }], "signature" : [{ "type" : [{ "system" : "urn:iso-astm:E1762-95:2013", "code" : "1.2.840.10065.1.12.1.20", "display" : "Electronic Signature" }], "when" : "2026-02-03T10:30:00+08:00", "who" : { "reference" : "Practitioner/K4-Practitioner", "display" : "Practitioner" }, "data" : "QkFTRTY0X1NJR05BVFVSRV9QQVRJRU5U" }] }, "request" : { "method" : "POST", "url" : "Provenance" } }, { "fullUrl" : "urn:uuid:claim", "resource" : { "resourceType" : "Claim", "id" : "CF4-Claim", "meta" : { "profile" : ["https://nhdr.gov.ph/fhir/StructureDefinition/PH-Claim"] }, "text" : { "status" : "extensions", "div" : "

Generated Narrative: Claim CF4-Claim

Profile: PH Claim

Encounter (Extension): Encounter

identifier: https://nhdr.gov.ph/claim/CLAIM-0001

status: Active

type: Institutional

use: Claim

patient: Patient

created: 2026-03-17

provider: Organization

priority: Normal

prescription: MedicationRequest

referral: ServiceRequest

supportingInfo

sequence: 1

category: Pertinent Past Medical History

value: Observation

supportingInfo

sequence: 2

category: Signs and Symptoms

value: Observation

supportingInfo

sequence: 3

category: Physical Examination

value: Observation

Diagnoses

-SequenceDiagnosis[x]
*1Hypertension

Procedures

-SequenceProcedure[x]
*1Procedure

Insurances

-SequenceFocalCoverage
*1trueCoverage

item

sequence: 1

productOrService: General Ward

quantity: 1

Nets

-ValueCurrency
*1000Philippine piso
" }, "extension" : [{ "url" : "https://nhdr.gov.ph/fhir/StructureDefinition/EncounterExtension", "valueReference" : { "reference" : "Encounter/CF4-Encounter", "display" : "Encounter" } }], "identifier" : [{ "system" : "https://nhdr.gov.ph/claim", "value" : "CLAIM-0001" }], "status" : "active", "type" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/claim-type", "code" : "institutional" }] }, "use" : "claim", "patient" : { "reference" : "Patient/CF4-Patient", "display" : "Patient" }, "created" : "2026-03-17", "provider" : { "reference" : "Organization/CF4-Organization", "display" : "Organization" }, "priority" : { "coding" : [{ "system" : "http://terminology.hl7.org/CodeSystem/processpriority", "code" : "normal" }] }, "prescription" : { "reference" : "MedicationRequest/CF4-MedicationRequest", "display" : "MedicationRequest" }, "referral" : { "reference" : "ServiceRequest/CF4-ServiceRequest", "display" : "ServiceRequest" }, "supportingInfo" : [{ "sequence" : 1, "category" : { "text" : "Pertinent Past Medical History" }, "valueReference" : { "reference" : "Observation/CF4-Observation-Pertinent-Past-Medical-History", "display" : "Observation" } }, { "sequence" : 2, "category" : { "text" : "Signs and Symptoms" }, "valueReference" : { "reference" : "Observation/CF4-Observation-Pertinent-Signs-and-Symptoms-on-Admission", "display" : "Observation" } }, { "sequence" : 3, "category" : { "text" : "Physical Examination" }, "valueReference" : { "reference" : "Observation/CF4-Observation-Physical-Examination-on-Admission", "display" : "Observation" } }], "diagnosis" : [{ "sequence" : 1, "diagnosisCodeableConcept" : { "text" : "Hypertension" } }], "procedure" : [{ "sequence" : 1, "procedureReference" : { "reference" : "Procedure/CF2-Procedure", "display" : "Procedure" } }], "insurance" : [{ "sequence" : 1, "focal" : true, "coverage" : { "reference" : "Coverage/K1-Coverage", "display" : "Coverage" } }], "item" : [{ "sequence" : 1, "productOrService" : { "text" : "General Ward" }, "quantity" : { "value" : 1 }, "net" : { "value" : 1000, "currency" : "PHP" } }] }, "request" : { "method" : "POST", "url" : "Claim" } }] }