NHDR Implementation Guide Release 1.0
0.1.0 - ci-build

NHDR Implementation Guide Release 1.0, published by NHDR. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/PROJ-PHILHEALTH-EA-NHDR/nhdr-fhir-ig-review-project-2/ and changes regularly. See the Directory of published versions

## Example Bundle: ClaimsForm3

Bundle ClaimsForm3 of type transaction

Entry 1 - fullUrl = urn:uuid:patient

Resource Patient:

> Generated Narrative: Patient CF3-Patient

> Profile: PH Patient

> John Mark Apilyido (no stated gender), DoB Unknown

Request:

    POST Patient

Entry 2 - fullUrl = urn:uuid:organization

Resource Organization:

> Generated Narrative: Organization CF3-Organization

> Profile: PH Organization

> identifier: PhilHealth Accreditation Number (PAN)/AN55555

> name: Pasig General Hospital

Request:

    POST Organization

Entry 3 - fullUrl = urn:uuid:encounter

Resource Encounter:

> Generated Narrative: Encounter CF3-Encounter

> Profile: PH Encounter

> status: booked

> class: ActCode: AMB (ambulatory)

> period: 2024-07-18 08:00:00+0800 --> 2024-07-18 10:00:00+0800

> reasonReference: Observation

> ### Hospitalizations

> - | DischargeDisposition
> * | Discharged to home

Request:

    POST Encounter

Entry 4 - fullUrl = urn:uuid:observation

Resource Observation:

> Generated Narrative: Observation CF3-Observation-Physical-Examination

> Profile: PH Observation

> status: Final

> code: Physical examination

> value: Patient complains of severe headache

> > component

> > code: General Survey

> > value: Patient appears weak

> > component

> > code: Vital Signs - BP

> > value: 120/80 mmHg

> > component

> > code: Vital Signs - CR

> > value: 78 bpm

> > component

> > code: Vital Signs - RR

> > value: 18 breaths/min

> > component

> > code: Vital Signs - Temperature

> > value: 36.8°C

> > component

> > code: Abdomen

> > value: Soft, non-tender, no organomegaly

> > component

> > code: HEENT

> > value: Pupils equal, round, reactive to light; oropharynx clear

> > component

> > code: GU (IE)

> > value: Normal external genitalia; no masses or tenderness

> > component

> > code: Chest/Lungs

> > value: Clear to auscultation bilaterally; no wheezes or crackles

> > component

> > code: Skin/Extremities

> > value: Skin warm and dry; no rashes; peripheral pulses palpable

> > component

> > code: CVS

> > value: Heart sounds normal; regular rate and rhythm; no murmurs

> > component

> > code: Neuro Examination

> > value: Alert, cranial nerves II-XII intact; motor and sensory exam normal

Request:

    POST Observation

Entry 5 - fullUrl = urn:uuid:observation

Resource Observation:

> Generated Narrative: Observation CF3-Observation-Pertinent-Laboratory

> Profile: PH Observation

> status: Final

> code: Pertinent Laboratory

> ### Components

> - | Code | Value[x]
> * | CBC | Normal

Request:

    POST Observation

Entry 6 - fullUrl = urn:uuid:observation

Resource Observation:

> Generated Narrative: Observation CF3-Observation-Pregnancy-Risk-Assessment

> Profile: PH Observation

> status: Final

> code: Pregnancy risk assessment

> > component

> > code: Vital signs

> > interpretation: Normal

> > component

> > code: Pregnancy Low Risk

> > value: true

> > component

> > code: Menstrual History - Last Menstrual Period (LMP)

> > value: 2026-02-10

> > component

> > code: Menstrual History - Age of Menarche

> > value: 13

> > component

> > code: Obstetric History (G)

> > value: 2

> > component

> > code: Obstetric History (P)

> > value: 1

> > component

> > code: Obstetric History (P)[T]

> > value: 1

> > component

> > code: Obstetric History (P)[P]

> > value: 0

> > component

> > code: Obstetric History (P)[A]

> > value: 0

> > component

> > code: Obstetric History (P)[L]

> > value: 1

Request:

    POST Observation

Entry 7 - fullUrl = urn:uuid:observation

Resource Observation:

> Generated Narrative: Observation CF3-Observation-Obstetric-Risk-Factors

> Profile: PH Observation

> status: Final

> code: Obstetric risk factors

> > component

> > code: Multiple pregnancy

> > value: false

> > component

> > code: Ovarian cyst

> > value: true

> > component

> > code: Myoma uteri

> > value: false

> > component

> > code: Placenta previa

> > value: false

> > component

> > code: History of 3 miscarriages

> > value: true

> > component

> > code: History of stillbirth

> > value: false

> > component

> > code: History of pre-eclampsia

> > value: true

> > component

> > code: History of eclampsia

> > value: false

> > component

> > code: Premature contraction

> > value: true

Request:

    POST Observation

Entry 8 - fullUrl = urn:uuid:observation

Resource Observation:

> Generated Narrative: Observation CF3-Observation-Estimated-Delivery-Date

> Profile: PH Observation

> status: Final

> code: Delivery date Estimated

> effective: 2026-03-10

Request:

    POST Observation

Entry 9 - fullUrl = urn:uuid:observation

Resource Observation:

> Generated Narrative: Observation CF3-Observation-Age-of-Gestation

> Profile: PH Observation

> status: Final

> code: Age of Gestation

> value: 20 weeks

Request:

    POST Observation

Entry 10 - fullUrl = urn:uuid:observation

Resource Observation:

> Generated Narrative: Observation CF3-Observation-Weight-and-Vital-Signs

> Profile: PH Observation

> status: Final

> code: Vital signs panel

> > component

> > code: Weight

> > value: 65 kg

> > component

> > code: Cardiac Rate

> > value: 80 beats/minute

> > component

> > code: Respiratory Rate

> > value: 18 breaths/minute

> > component

> > code: Blood Pressure

> > value: 120/80 mmHg

> > component

> > code: Temperature

> > value: 36.8 °C

Request:

    POST Observation

Entry 11 - fullUrl = urn:uuid:observation

Resource Observation:

> Generated Narrative: Observation CF3-Observation-Pregnancy-status-panel

> Profile: PH Observation

> status: Final

> code: Pregnancy status panel

> > component

> > code: Maternal Outcome - Obstetric Index

> > value: G2P1 (1-0-0-1)

> > component

> > code: Pregnancy Uterine - AOG by LMP

> > value: 20 weeks

> > component

> > code: Pregnancy Uterine - Manner of Delivery

> > value: Normal Spontaneous Vaginal Delivery

> > component

> > code: Pregnancy Uterine - Presentation

> > value: Cephalic

Request:

    POST Observation

Entry 12 - fullUrl = urn:uuid:observation

Resource Observation:

> Generated Narrative: Observation CF3-Observation-Birth-Outcome-Panel

> Profile: PH Observation

> status: Final

> code: Birth outcome panel

> > component

> > code: Birth Outcome - Fetal Outcome

> > value: Live birth

> > component

> > code: Birth Outcome - Sex

> > value: Male

> > component

> > code: Birth Outcome - Birth Weight (grm)

> > value: 3200 g

> > component

> > code: Birth Outcome - APGAR Score

> > value: 9

Request:

    POST Observation

Entry 13 - fullUrl = urn:uuid:clinicalimpression

Resource ClinicalImpression:

> Generated Narrative: ClinicalImpression CF3-ClinicalImpression

> Profile: PH ClinicalImpression

> status: Completed

> description: Patient admitted for observation and management of hypertension. During the ward stay, vital signs stabilized, medications were adjusted, and patient responded well to treatment. No complications noted. Discharged in stable condition.

> subject: John Mark Apilyido (no stated gender), DoB Unknown

Request:

    POST ClinicalImpression

Entry 14 - fullUrl = urn:uuid:diagnosticreport

Resource DiagnosticReport:

> Generated Narrative: DiagnosticReport CF3-DiagnosticReport

> Profile: PH DiagnosticReport

> ## Anemia, unspecified

> Report Details

> Patient shows mild anemia with hemoglobin slightly below normal range; other CBC parameters within normal limits.

Request:

    POST DiagnosticReport

Entry 15 - fullUrl = urn:uuid:provenance

Resource Provenance:

> Generated Narrative: Provenance CF3-Provenance

> Profile: PH Provenance

> Provenance for Claim: extension = ->Encounter; status = active; type = Institutional; use = claim; created = 2024-07-18; priority = Normal

> Summary

> Recorded | 2026-02-03 09:00:00+0800

> Agents

> who
> Practitioner

Request:

    POST Provenance

Entry 16 - fullUrl = urn:uuid:questionnaire

Resource Questionnaire:

> Generated Narrative: Questionnaire CF3-Questionnaire

> Profiles: PH Questionnaire, `https://nhdr.gov.ph/fhir/StructureDefinition/PH_Questionnaire`

> LinkID | Text | Cardinality | Type | Description & Constraints
> --- | --- | --- | --- | ---
> |  |  | Questionnaire |
> CF3-Q1 | Orientation to MCP/Availment of Benefits (Yes/No) | 0..1 | boolean |
> CF3-Q2 | Perineal wound care | 0..1 | boolean |
> CF3-Q3 | Perineal wound care - Remarks | 0..1 | string |
> CF3-Q4 | Signs of Maternal Postpartum Complications | 0..1 | boolean |
> CF3-Q5 | Signs of Maternal Postpartum Complications - Remarks | 0..1 | string |
> CF3-Q6 | Counselling and Education (Breastfeeding and Nutrition) | 0..1 | boolean |
> CF3-Q7 | Counselling and Education (Breastfeeding and Nutrition) - Remarks | 0..1 | string |
> CF3-Q8 | Counselling and Education (Family Planning) | 0..1 | boolean |
> CF3-Q9 | Counselling and Education (Family Planning) - Remarks | 0..1 | string |
> CF3-Q10 | Provided family planning service to patient (as requested by patient) | 0..1 | boolean |
> CF3-Q11 | Provided family planning service to patient (as requested by patient) - Remarks | 0..1 | string |
> CF3-Q12 | Referred to partner physician for Voluntary Surgical Sterilization (as requested by pt.) | 0..1 | boolean |
> CF3-Q13 | Referred to partner physician for Voluntary Surgical Sterilization (as requested by pt.) - Remarks | 0..1 | string |
> CF3-Q14 | Schedule the next postpartum follow-up | 0..1 | boolean |
> CF3-Q15 | Schedule the next postpartum follow-up - Remarks | 0..1 | string |
> Documentation for this format

Request:

    POST Questionnaire

Entry 17 - fullUrl = urn:uuid:questionnaireresponse

Resource QuestionnaireResponse:

> Generated Narrative: QuestionnaireResponse CF3-QuestionnaireResponse

> Profiles: PH QuestionnaireResponse, `https://nhdr.gov.ph/fhir/StructureDefinition/PH_QuestionnaireResponse`

> LinkID | Text | Definition | Answer
> --- | --- | --- | ---
> CF3-QuestionnaireResponse |  |  | Questionnaire:None specified
> CF3-Q1 |  |  | true
> CF3-Q2 |  |  | true
> CF3-Q3 |  |  | Patient instructed on proper perineal hygiene and wound care.
> CF3-Q4 |  |  | true
> CF3-Q5 |  |  | Patient advised to watch for fever, excessive bleeding, and severe abdominal pain.
> CF3-Q6 |  |  | true
> CF3-Q7 |  |  | Counselling provided on exclusive breastfeeding and balanced nutrition.
> CF3-Q8 |  |  | true
> CF3-Q9 |  |  | Discussed available family planning methods suitable for postpartum mothers.
> CF3-Q10 |  |  | false
> CF3-Q11 |  |  | Patient opted to decide on family planning method at next visit.
> CF3-Q12 |  |  | false
> CF3-Q13 |  |  | No referral requested by patient.
> CF3-Q14 |  |  | true
> CF3-Q15 |  |  | Next postpartum follow-up scheduled after 6 weeks.
> Documentation for this format

Request:

    POST QuestionnaireResponse

Entry 18 - fullUrl = urn:uuid:claim

Resource Claim:

> Generated Narrative: Claim CF3-Claim

> Profiles: PH Claim, `https://nhdr.gov.ph/fhir/StructureDefinition/PH_Claim`

> Encounter (Extension): Encounter

> status: Active

> type: Institutional

> use: Claim

> patient: Patient

> created: 2024-07-18

> provider: Organization

> priority: Normal

> > supportingInfo

> > sequence: 1

> > category: Physical Examination

> > value: Observation

> > supportingInfo

> > sequence: 2

> > category: Laboratory

> > value: Observation

> > supportingInfo

> > sequence: 3

> > category: Pregnancy Risk Assessment

> > value: Observation

> > supportingInfo

> > sequence: 4

> > category: Obstetric Risk Factors

> > value: Observation

> > supportingInfo

> > sequence: 5

> > category: Estimated Delivery Date

> > value: Observation

> > supportingInfo

> > sequence: 6

> > category: Age of Gestation

> > value: Observation

> > supportingInfo

> > sequence: 7

> > category: Weight and Vital Signs

> > value: Observation

> > supportingInfo

> > sequence: 8

> > category: Pregnancy Status Panel

> > value: Observation

> > supportingInfo

> > sequence: 9

> > category: Birth Outcome Panel

> > value: Observation

> > diagnosis

> > sequence: 1

> > diagnosis: Condition

> > diagnosis

> > sequence: 2

> > diagnosis: Moderate persistent asthma

> ### Insurances

> - | Sequence | Focal | Coverage
> * | 1 | true | Coverage

> ### Items

> - | Sequence | ProductOrService | Serviced[x]
> * | 1 | Maternity Care Package Service | 2024-07-18

Request:

    POST Claim