Lampiran Terminologi INC

Observation.valueCodeableConcept untuk Keadaan Ibu

Tabel 1. Observation.valueCodeableConcept untuk Keadaan Ibu
Observation.valueCodeableConcept.coding.systemObservation.valueCodeableConcept.coding.codeObservation.valueCodeableConcept.coding.displayPilihan jawaban yang divisualisasikan

http://snomed.info/sct

102514002

Well female adult

Sehat

39104002

Illness

Sakit

47821001

Postpartum hemorrhage

Perdarahan

386661006

Fever

Demam

91175000

Seizure

Kejang

249215002

Odor of lochia

Lokhia Berbau

74964007

Other

Lain-Lain

Observation.valueCodeableConcept untuk Penolong Persalinan

Tabel 2. Observation.valueCodeableConcept untuk Penolong Persalinan
SystemCodeDisplayPilihan jawaban yang divisualisasikan

http://snomed.info/sct

303071001

Person in the family

Keluarga

http://terminology.kemkes.go.id/CodeSystem/clinical-term

OV000012

Dukun

Dukun

http://snomed.info/sct

309453006

Registered midwife

Bidan

309343006

Physician Occupation

Dokter

11935004

Obstetrician Occupation

Dokter Spesialis

249215002

Odor of lochia

Lokhia Berbau

Observation.interpretation untuk Berat Badan Bayi Saat Lahir

Tabel 3. Observation.interpretation untuk Berat Badan Bayi Saat Lahir
Observation.interpretation.coding.systemObservation.Interpretation.coding.codeObservation.Interpretation.coding.displayPilihan jawaban yang divisualisasikanDeskripsi

http://terminology.kemkes.go.id/CodeSystem/clinical-term

276613009

High birth weight

BBLB (Bayi Berat Lahir Besar)

>=4000gr 2500gr s/d

276712009

Normal birth weight

BBLC (Bayi Berat Lahir Cukup)

<4000gr

276610007

Low birth weight infant

BBLR (Bayi Berat Lahir Rendah)

1500 s/d 2499 gr

276611006

Very low birth weight infant

BBLSR (bayi Berat Lahir Sangat Rendah)

1000 s/d 1499 gr

276612004

Extremely low birth weight

BLASR (Bayi Berat Lahir Amat Sangat Rendah)

<1000gr

Observation.valueCodeableConcept untuk Lokasi Persalinan

Tabel 4. Observation.valueCodeableConcept untuk Lokasi Persalinan
SystemCodeDisplayPilihan jawaban yang divisualisasikan

http://snomed.info/sct

264362003

Home

Rumah

http://terminology.kemkes.go.id/CodeSystem/organization-type

OT000001

Polindes

Polindes

OT000002

Pustu

Pustu

102

Pusat Kesehatan Masyarakat

Puskesmas

103

Klinik

Klinik

http://snomed.info/sct

394573001

Maternity clinic

Rumah Bersalin

82242000

Children’s hospital

Rumah Sakit Ibu dan Anak

hhttp://terminology.kemkes.go.id/CodeSystem/organization-type

104

Rumah Sakit

Rumah Sakit

OT000003

RS ODHA

RS ODHA

OT000004

Bidan Praktek Mandiri

Bidan Praktek Mandiri

Matriks Skenario Peresepan dan Pengeluaran Obat

Keterangan :
* NC : Non-compound (non racikan)
* SD : Give of such doses (dtd)
* EP : Divide into equal part (tablet dipecah).
Tabel 5. Matriks Skenario Peresepan dan Pengeluaran Obat

Use Case

Medication.code MedicationRequest

Medication.ingredient MedicationRequest

MedicationRequest

Medication.code MedicationDispense

Medication.ingredient MedicationDispense

MedicationDispense (Instruction)

Valid/Invalid

Obat Pakem Tunggal (NC)

R/ Paracetamol 500 mg

93xxx

-

-

93xxx

-

Valid

92xxx

-

-

93xxx

-

Valid (Dengan ketentuan kode 93 untuk Medication.code MedicationDispense sebaiknya merupakan turunan dari kode 92 di Medication.code MedicationRequest)

91xxx

-

-

93xxx

-

Invalid

Racikan Non-dtd (EP)

  • R/ Paracetamol 500 mg 10 tab

  • Vitamin B6 10mg 10 tab

  • Dibuat 30 kapsul

-

Paracetamol:

  • Medication.ingredient.itemCodeableConcept → 93xxx

  • Medication.ingredient.strength.num : 10/tab

  • Medication.ingredient.strength.denominator : 30/kap

MedicationRequest.dispenseRequest.quantity → 30

-

  • Medication.ingredient.itemCodeableConcept → 93xxx

  • Medication.ingredient.strength.numerator : 10/tab

  • Medication.ingredient.strength.denominator : 30/kap

MedicationDispense.quantity → 30

Valid

-

Vitamin B6:

  • Medication.ingredient.itemCodeableConcept→ 92xxx

  • Medication.ingredient.strength.numerator: 10/tab

  • Medication.ingredient.strength.denominator: 30/kap

MedicationRequest.dispenseRequest.quantity → 30

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 10/tab

  • Medication.ingredient.strength.denominator: 30/kap

MedicationDispense.quantity → 30

Valid

Racikan dtd (SD/ tidak ada sisa)

  • R/ Paracetamol 125 mg/ kapsul > perlu 5 tab (20 kapsul x 125 / 500mg)

  • Vitamin B6 20 mg/ kapsul > perlu 40 tab (20 kapsul x 20 / 10mg)

  • Dibuat 20 kapsul

-

Paracetamol:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 125/mg

  • Medication.ingredient.strength.denominator: 1/kap

MedicationRequest.dispenseRequest.quantity → 20

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 5/tab

  • Medication.ingredient.strength.denominator: 20/kap

MedicationDispense.quantity → 20

Valid

-

Vitamin B6:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 20/mg

  • Medication.ingredient.strength.denominator: 1/kap

MedicationRequest.dispenseRequest.quantity → 20

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 40/tab

  • Medication.ingredient.strength.denominator: 20/kap

MedicationDispense.quantity → 20

Valid

Racikan dtd (SD/ ada sisa)

Narkotika

  • R/ Morphine Hydrochloride 3 mg > perlu 7.5 tab (25 kapsul x 3 / 10mg)

  • Diazepam 1 mg Tablet > perlu 12,5 tab (25 kapsul x 1 / 2mg)

  • Dibuat 25 kapsul

-

Morphine Hydrochloride

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 3/mg

  • Medication.ingredient.strength.denominator: 1/tab

MedicationRequest.dispenseRequest.quantity → 25

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 7,5/tab

  • Medication.ingredient.strength.denominator: 25/kapsul

MedicationDispense.quantity → 25

Valid (Penulisan di Medication.ingredient.strength.numerator Medication Dispense sesuai yaitu 7.5tab, tidak dilakukan pembulatan)

-

Diazepam

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 3/mg

  • Medication.ingredient.strength.denominator: 1/tab

MedicationRequest.dispenseRequest.quantity → 25

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 12,5/tab

  • Medication.ingredient.strength.denominator: 25/kapsul

MedicationDispense.quantity → 25

Valid (Penulisan di Medication.ingredient.strength.numerator Medication Dispense sesuai yaitu 12.5tab, tidak dilakukan pembulatan)

Non-Narkotika

  • R/ Paracetamol 125 mg/ kapsul > perlu 7.5 tab (30 kapsul x 125 /500mg)

  • Vitamin B6 12,5 mg/ kapsul > perlu 37,5 tab (30 kapsul x 12,5 / 10mg)

  • Dibuat 30 kapsul

-

Paracetamol:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 125/mg

  • Medication.ingredient.strength.denominator: 1/tab

MedicationRequest.dispenseRequest.quantity → 30

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 8/tab

  • Medication.ingredient.strength.denominator: 30/kapsul

MedicationDispense.quantity → 30

Valid (Penulisan di Medication.ingredient.strength.numerator Medication Dispense adalah pembulatan ke atas yaitu dari 7.5 tab menjadi 8tab, tetapi yang digunakan tetap 7,5tab)

-

Vitamin B6:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 12.5/mg

  • Medication.ingredient.strength.denominator: 1/tab

MedicationRequest.dispenseRequest.quantity → 30

-

  • Medication.ingredient.itemCodeableConcept→ 93xxx

  • Medication.ingredient.strength.numerator: 37.5/tab

  • Medication.ingredient.strength.denominator: 30/kap

MedicationDispense.quantity → 30

Valid (Penulisan di Medication.ingredient.strength.numerator Medication Dispense adalah pembulatan ke atas yaitu dari 37.5 tab menjadi 38tab, tetapi yang digunakan tetap 37,5tab)

Obat Minum (NC tidak sisa)

  • R/ Paracetamol 120 mg/5 mL Sirup

  • Paracetamol 5 ml diminum 4-6 jam sekali bila demam selama 24 hari

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

Valid

92xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

Valid

Obat Minum (NC sisa)

  • R/ Paracetamol 120 mg/5 mL Sirup

  • Paracetamol 5 ml diminum 4-6 jam sekali bila demam selama 30 hari

  • 1 botol 60 ml maka diperlukan 5mlx30 / 60ml = 2.5

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

Valid (Perlu catatan dari dokter obatnya harus dihabiskan atau tidak)

92xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

Valid

Obat Minum (NC sisa)

  • R/ Paracetamol 120 mg/5 mL Sirup

  • Paracetamol 5 ml diminum 4-6 jam sekali bila demam selama 30 hari

  • 1 botol 60 ml maka diperlukan 5mlx30 / 60ml = 2.5

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

Valid (Perlu catatan dari dokter obatnya harus dihabiskan atau tidak)

92xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

93xxx

Paracetamol Sirup

  • Medication.ingredient.itemCodeableConcept → 91xxx

  • Medication.ingredient.strength.numerator : 120 mg

  • Medication.ingredient.strength.denominator : 5mL

-

Valid

Obat Suntik (NC tidak sisa)

  • R/ Insulin Human Analog (Rapid Acting) 100 IU/mL Injeksi (NOVORAPID, 3 mL)

  • Suntik 3 kali sehari 10 Unit sebelum makan selama 30 hari - perlu 3 cartridge (100IU/ml x 3 mL / (3x10IU) = 10 hari 1 cartridge

  • 30 hari maka perlu 30/10 = 3 cartridge

93xxx

Insulin Human Analog:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 100[U]

  • Medication.ingredient.strength.denominator: 1/mL

-

93xxx

Insulin Human Analog :

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 3/cartridge

  • Medication.ingredient.strength.denominator: 9/mL

-

Valid

92xxx

Insulin Human Analog:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 100[U]

  • Medication.ingredient.strength.denominator: 1/mL

-

93xxx

Insulin Human Analog :

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 3/cartridge

  • Medication.ingredient.strength.denominator: 9/mL

-

Valid

Obat Suntik (NC sisa)

  • R/ Insulin Human Analog (Rapid Acting) 100 IU/mL Injeksi (NOVORAPID, 3 mL)

  • Suntik 3 kali sehari 8 Unit sebelum makan selama 30 hari - perlu 3 cartridge (100IU/ml x 3 mL / (3x8IU) = 12,5 hari 1 cartridge

  • 30 hari maka perlu 30/12.5= 2.4 cartridge

93xxx

Insulin Human Analog:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 100[U]

  • Medication.ingredient.strength.denominator: 1/mL

-

93xxx

Insulin Human Analog :

  • Medication.ingredient.itemCodeableConcept→ 91/xxx

  • Medication.ingredient.strength.numerator: 2.4 cartridge

  • Medication.ingredient.strength.denominator: 7.2/mL

-

Valid (Perlu catatan dari dokter obatnya harus dihabiskan atau tidak)

92xxx

Insulin Human Analog:

  • Medication.ingredient.itemCodeableConcept→ 91xxx

  • Medication.ingredient.strength.numerator: 100[U]

  • Medication.ingredient.strength.denominator: 1/mL

-

93xxx

Insulin Human Analog :

  • Medication.ingredient.itemCodeableConcept→ 91/xxx

  • Medication.ingredient.strength.numerator: 2.4 cartridge

  • Medication.ingredient.strength.denominator: 7.2/mL

-

Valid