# ClaimsForm4 - NHDR Implementation Guide Release 1.0 v0.1.0

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **ClaimsForm4**

## Example Bundle: ClaimsForm4



## Resource Content

```json
{
  "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Patient_CF4-Patient\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Patient CF4-Patient</b></p><a name=\"CF4-Patient\"> </a><a name=\"hcCF4-Patient\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Patient.html\">PH Patient</a></p></div><p style=\"border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;\">John Mark Apilyido  (no stated gender), DoB Unknown ( PhilHealth ID: PH-00001)</p><hr/><table class=\"grid\"><tr><td style=\"background-color: #f3f5da\" title=\"Extension to capture the sex of a patient, practitioner, or person.\"><a href=\"StructureDefinition-Sex.html\">Sex at birth</a></td><td colspan=\"3\">M</td></tr></table></div>"
      },
      "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Organization_CF4-Organization\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Organization CF4-Organization</b></p><a name=\"CF4-Organization\"> </a><a name=\"hcCF4-Organization\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Organization.html\">PH Organization</a></p></div><p><b>identifier</b>: PhilHealth Accreditation Number (PAN)/AN199513893</p><p><b>name</b>: 6th General Hospital</p><p><b>address</b>: 572 BLK 2 LOT 21 Maharlika Village 2300 </p></div>"
      },
      "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Encounter_CF4-Encounter\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Encounter CF4-Encounter</b></p><a name=\"CF4-Encounter\"> </a><a name=\"hcCF4-Encounter\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Encounter.html\">PH Encounter</a></p></div><p><b>Age in Years</b>: 35</p><p><b>status</b>: Finished</p><p><b>class</b>: <a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-v3-ActCode.html#v3-ActCode-AMB\">ActCode: AMB</a> (Ambulatory)</p><p><b>period</b>: 2026-03-11 08:00:00+0800 --&gt; 2026-03-11 09:30:00+0800</p><p><b>reasonReference</b>: <a href=\"Bundle-ClaimsForm4.html#Observation_CF4-Observation-Pertinent-Past-Medical-History\">Observation</a></p><h3>Hospitalizations</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>DischargeDisposition</b></td></tr><tr><td style=\"display: none\">*</td><td><span title=\"Codes:{http://terminology.hl7.org/CodeSystem/discharge-disposition home}\">Discharged to home</span></td></tr></table></div>"
      },
      "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Condition_CF4-Condition\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Condition CF4-Condition</b></p><a name=\"CF4-Condition\"> </a><a name=\"hcCF4-Condition\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Condition.html\">PH Condition</a></p></div><p><b>code</b>: <span title=\"Codes:{http://hl7.org/fhir/sid/icd-10 I10}\">Essential (primary) hypertension</span></p><p><b>subject</b>: <a href=\"Bundle-ClaimsForm4.html#Patient_CF4-Patient\">Patient</a></p><p><b>note</b>: , </p><blockquote><div><p>Patient reports persistent headaches for the past 2 weeks.</p>\n</div></blockquote><blockquote><div><p>Past medical history includes type 2 diabetes mellitus, controlled on metformin.</p>\n</div></blockquote></div>"
      },
      "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_CF4-Observation-Pertinent-Past-Medical-History\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation CF4-Observation-Pertinent-Past-Medical-History</b></p><a name=\"CF4-Observation-Pertinent-Past-Medical-History\"> </a><a name=\"hcCF4-Observation-Pertinent-Past-Medical-History\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Observation.html\">PH Observation</a></p></div><p><b>status</b>: Final</p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 57075-4}\">Pregnancy history panel</span></p><p><b>dataAbsentReason</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/data-absent-reason not-applicable}\">Not Applicable</span></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">OB/GYN History (G)</span></p><p><b>value</b>: 3</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">OB/GYN History (P)</span></p><p><b>value</b>: 2</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">OB/GYN History (P)(T)</span></p><p><b>value</b>: 1</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">OB/GYN History (P)(P)</span></p><p><b>value</b>: 1</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">OB/GYN History (P)(A)</span></p><p><b>value</b>: 0</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">OB/GYN History (P)(L)</span></p><p><b>value</b>: 2</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">OB/GYN History - LMP</span></p><p><b>value</b>: 2026-02-01</p></blockquote></div>"
      },
      "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_CF4-Observation-Pertinent-Signs-and-Symptoms-on-Admission\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation CF4-Observation-Pertinent-Signs-and-Symptoms-on-Admission</b></p><a name=\"CF4-Observation-Pertinent-Signs-and-Symptoms-on-Admission\"> </a><a name=\"hcCF4-Observation-Pertinent-Signs-and-Symptoms-on-Admission\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Observation.html\">PH Observation</a></p></div><p><b>status</b>: Final</p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 75325-1}\">Pertinent signs and symptoms on admission</span></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Altered mental sensorium</span></p><p><b>value</b>: true</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Abdominal cramp/pain</span></p><p><b>value</b>: true</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Anorexia</span></p><p><b>value</b>: false</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Bleeding gum</span></p><p><b>value</b>: false</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Body weakness</span></p><p><b>value</b>: true</p></blockquote></div>"
      },
      "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Observation_CF4-Observation-Physical-Examination-on-Admission\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Observation CF4-Observation-Physical-Examination-on-Admission</b></p><a name=\"CF4-Observation-Physical-Examination-on-Admission\"> </a><a name=\"hcCF4-Observation-Physical-Examination-on-Admission\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Observation.html\">PH Observation</a></p></div><p><b>status</b>: Final</p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 29545-1}\">Physical findings on admission</span></p><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 8302-2}\">Body height</span></p><p><b>value</b>: 160 cm</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 29463-7}\">Body weight</span></p><p><b>value</b>: 65 kg</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 80313-0}\">Mental status - level of consciousness</span></p><p><b>value</b>: Awake and alert</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 85354-9}\">Blood pressure panel</span></p><p><b>value</b>: 120/80 mmHg</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 8867-4}\">Heart rate</span></p><p><b>value</b>: 82 beats/min</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 9279-1}\">Respiratory rate</span></p><p><b>value</b>: 20 breaths/min</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:{http://loinc.org 8310-5}\">Body temperature</span></p><p><b>value</b>: 37 °C</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">HEENT</span></p><p><b>value</b>: Essentially Normal</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Chest/Lungs</span></p><p><b>value</b>: Symmetrical chest expansion</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">CVS</span></p><p><b>value</b>: Displaced apex beat</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Abdomen</span></p><p><b>value</b>: Abdominal rigidity</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">GU (IE)</span></p><p><b>value</b>: Blood stained on examining finger</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Skin/Extremities</span></p><p><b>value</b>: Rashes/petechiae</p></blockquote><blockquote><p><b>component</b></p><p><b>code</b>: <span title=\"Codes:\">Neuro Exam</span></p><p><b>value</b>: Essentially normal</p></blockquote></div>"
      },
      "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ServiceRequest_CF4-ServiceRequest\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ServiceRequest CF4-ServiceRequest</b></p><a name=\"CF4-ServiceRequest\"> </a><a name=\"hcCF4-ServiceRequest\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-ServiceRequest.html\">PH ServiceRequest</a></p></div><p><b>status</b>: Completed</p><p><b>intent</b>: Order</p><p><b>subject</b>: <a href=\"Bundle-ClaimsForm4.html#Patient_CF4-Patient\">Patient</a></p><p><b>requester</b>: <a href=\"Bundle-ClaimsForm4.html#Organization_CF4-Organization\">Organization</a></p><p><b>reasonReference</b>: <a href=\"Bundle-ClaimsForm4.html#Observation_CF4-Observation-Physical-Examination-on-Admission\">Observation</a></p></div>"
      },
      "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"ClinicalImpression_CF4-ClinicalImpression\"> </a><p class=\"res-header-id\"><b>Generated Narrative: ClinicalImpression CF4-ClinicalImpression</b></p><a name=\"CF4-ClinicalImpression\"> </a><a name=\"hcCF4-ClinicalImpression\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-ClinicalImpression.html\">PH ClinicalImpression</a></p></div><p><b>status</b>: Completed</p><p><b>description</b>: Clinical impression on admission based on history, pertinent signs and symptoms, and physical examination.</p><p><b>subject</b>: <a href=\"Bundle-ClaimsForm4.html#Patient_CF4-Patient\">Patient</a></p><p><b>effective</b>: 2026-03-12 09:30:00+0800</p></div>"
      },
      "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Provenance_CF4-Provenance\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Provenance CF4-Provenance</b></p><a name=\"CF4-Provenance\"> </a><a name=\"hcCF4-Provenance\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Provenance.html\">PH Provenance</a></p></div><p>Provenance for <a href=\"Bundle-ClaimsForm4.html#Claim_CF4-Claim\">Claim</a></p><p>Summary</p><table class=\"grid\"><tr><td>Recorded</td><td>2026-02-03 09:00:00+0800</td></tr></table><p><b>Agents</b></p><table class=\"grid\"><tr><td><b>who</b></td></tr><tr><td><a href=\"Bundle-Konsulta-Prescription-Slip.html#Practitioner_K4-Practitioner\">Practitioner</a></td></tr></table></div>"
      },
      "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" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><a name=\"Claim_CF4-Claim\"> </a><p class=\"res-header-id\"><b>Generated Narrative: Claim CF4-Claim</b></p><a name=\"CF4-Claim\"> </a><a name=\"hcCF4-Claim\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-PH-Claim.html\">PH Claim</a></p></div><p><b>Encounter (Extension)</b>: <a href=\"Bundle-ClaimsForm4.html#Encounter_CF4-Encounter\">Encounter</a></p><p><b>identifier</b>: <code>https://nhdr.gov.ph/claim</code>/CLAIM-0001</p><p><b>status</b>: Active</p><p><b>type</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/claim-type institutional}\">Institutional</span></p><p><b>use</b>: Claim</p><p><b>patient</b>: <a href=\"Bundle-ClaimsForm4.html#Patient_CF4-Patient\">Patient</a></p><p><b>created</b>: 2026-03-17</p><p><b>provider</b>: <a href=\"Bundle-ClaimsForm4.html#Organization_CF4-Organization\">Organization</a></p><p><b>priority</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/processpriority normal}\">Normal</span></p><p><b>prescription</b>: <a href=\"MedicationRequest/CF4-MedicationRequest\">MedicationRequest</a></p><p><b>referral</b>: <a href=\"Bundle-ClaimsForm4.html#ServiceRequest_CF4-ServiceRequest\">ServiceRequest</a></p><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 1</p><p><b>category</b>: <span title=\"Codes:\">Pertinent Past Medical History</span></p><p><b>value</b>: <a href=\"Bundle-ClaimsForm4.html#Observation_CF4-Observation-Pertinent-Past-Medical-History\">Observation</a></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 2</p><p><b>category</b>: <span title=\"Codes:\">Signs and Symptoms</span></p><p><b>value</b>: <a href=\"Bundle-ClaimsForm4.html#Observation_CF4-Observation-Pertinent-Signs-and-Symptoms-on-Admission\">Observation</a></p></blockquote><blockquote><p><b>supportingInfo</b></p><p><b>sequence</b>: 3</p><p><b>category</b>: <span title=\"Codes:\">Physical Examination</span></p><p><b>value</b>: <a href=\"Bundle-ClaimsForm4.html#Observation_CF4-Observation-Physical-Examination-on-Admission\">Observation</a></p></blockquote><h3>Diagnoses</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Diagnosis[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><span title=\"Codes:\">Hypertension</span></td></tr></table><h3>Procedures</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Procedure[x]</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td><a href=\"Bundle-ClaimsForm2.html#Procedure_CF2-Procedure\">Procedure</a></td></tr></table><h3>Insurances</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Sequence</b></td><td><b>Focal</b></td><td><b>Coverage</b></td></tr><tr><td style=\"display: none\">*</td><td>1</td><td>true</td><td><a href=\"Bundle-Konsulta-Registration.html#Coverage_K1-Coverage\">Coverage</a></td></tr></table><blockquote><p><b>item</b></p><p><b>sequence</b>: 1</p><p><b>productOrService</b>: <span title=\"Codes:\">General Ward</span></p><p><b>quantity</b>: 1</p><h3>Nets</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Value</b></td><td><b>Currency</b></td></tr><tr><td style=\"display: none\">*</td><td>1000</td><td>Philippine piso</td></tr></table></blockquote></div>"
      },
      "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"
    }
  }]
}

```
