Core Components

Patient

Every healthcare journey begins with a person - the patient. This component captures who they are, where they live, and important personal information that helps healthcare providers give them the best care possible.

Think of the patient record as the foundation of everything else. It's like the cover page of a medical file that tells you who this person is, how to contact them, and important details about their identity and background.

Data Model

Field	Type	Required	Description
code	string	YES	Unique identifier for the patient in the system
surname	string	YES	Patient's family name
name	string	YES	Patient's given name
sex	string	YES	Patient's biological sex
birthdate	date	YES	Patient's date of birth
phone	string	YES	Patient's contact number
nationality	string	YES	Patient's nationality
disabilities	array of strings		List of disabilities, if applicable
occupation	string		Patient's job or profession (nullable)
marital_status	string	YES	Patient's marital status (nullable)
photos	array of strings		URLs to patient photos (nullable)
address	object	YES	Patient's address information (see Address model)
identifications	array of objects		Patient identification documents (see Identification model)
death_date	datetime		Date and time of death, if applicable
spid	string	YES	Patient's Social Protection ID
created_at	datetime	YES	Record creation timestamp
updated_at	datetime	YES	Record the last update timestamp

Address Model

Cambodia uses a specific address structure based on NCDD standards:

Field	Type	Required	Description
province	object	YES	Information about the province
province.code	string	YES	Province code from NCDD standard
province.name	string	YES	Province's name in Khmer
district	object	YES	Information about the district
district.code	string	YES	District code from NCDD standard
district.name	string	YES	District name in Khmer
commune	object	YES	Information about the commune
commune.code	string	YES	Commune code from NCDD standard
commune.name	string	YES	Commune name in Khmer
village	object	YES	Information about the village
village.code	string	YES	Village code from NCDD standard
village.name	string	YES	Village name in Khmer
house_number	string		House number (nullable)
street_number	string		Street number (nullable)
location	string		Additional location details (nullable)

Identification Model

Field	Type	Required	Description
patient_code	string	YES	Reference to patient unique code
card_code	string	YES	Identification number
card_type	string	YES	Type of identification document

Example

{
  "patient": {
    "code": "P25003877",
    "surname": "សៅ",
    "name": "សុវ៉ាន់",
    "sex": "M",
    "birthdate": "1980-05-15",
    "phone": "+855 12 345 678",
    "nationality": "Cambodian",
    "disabilities": ["Hearing impairment"],
    "occupation": "Teacher",
    "marital_status": "Married",
    "photos": ["https://hospital.example/photos/PT20250317001_1.jpg"],
    "address": {
      "province": {
        "code": "12",
        "name": "Phnom Penh"
      },
      "district": {
        "code": "1201",
        "name": "Chamkar Mon"
      },
      "commune": {
        "code": "120101",
        "name": "Tonle Bassac"
      },
      "village": {
        "code": "12010101",
        "name": "Phsar Deum Thkov"
      },
      "house_number": "45",
      "street_number": "302",
      "location": "Near Central Market"
    },
    "identifications": [
      {
        "patient_code": "P25003877",
        "card_code": "ID123456789",
        "card_type": "National ID"
      }
    ],
    "death_date": null,
    "spid": "1234567890",
    "created_at": "2025-03-17T08:30:00.000+07:00",
    "updated_at": "2025-03-17T08:30:00.000+07:00"
  }
}

Visit

A visit is like opening a new chapter in the patient's medical story. It represents their entire stay at the hospital - from the moment they walk in (or are brought in) until they leave.

Every visit has a beginning and an end, and everything that happens in between gets connected to this visit. Think of it as the "container" that holds all the medical care, tests, treatments, and interactions that occur during this particular trip to the hospital.

Data Model

Field	Type	Required	Description
health_facility_code	string	YES	Unique identifier for the healthcare facility, issued by NPCA
patient_code	string	YES	Reference to the patient's unique code
code	string	YES	Unique identifier for the visit
admission_type	string	YES	How a patient is admitted to a healthcare facility
discharge_type	string	YES	How a patient is discharged from a healthcare facility
visit_outcome	string	YES	The patient's condition at the end of the visit
visit_type	string	YES	The type or purpose of a patient's visit (IPD or OPD)
admitted_at	datetime	YES	Date and time of admission
discharged_at	datetime	YES	Date and time of discharge
followup_at	datetime		When the patient is scheduled to return for follow-up care
created_at	datetime	YES	Record creation timestamp
updated_at	datetime	YES	Record the last update timestamp

Example

{
  "visits": [
    {
      "health_facility_code": "121020",
      "patient_code": "P25003877",
      "code": "V420650",
      "admission_type": "Walk-in",
      "discharge_type": "Authorized",
      "visit_outcome": "Improved",
      "visit_type": "OPD",
      "admitted_at": "2025-03-17T09:30:00.000+07:00",
      "discharged_at": "2025-03-17T10:45:00.000+07:00",
      "followup_at": "2025-03-24T09:00:00.000+07:00",
      "created_at": "2025-03-17T09:30:00.000+07:00",
      "updated_at": "2025-03-17T10:45:00.000+07:00"
    }
  ]
}

Triage

Triage is like the "first impression" of the patient's visit. When someone arrives at the hospital, a nurse or healthcare worker quickly assesses them to understand: How urgent is their condition? What are their main complaints? What are their basic vital measurements?

This is where the patient's story begins to unfold. The triage nurse asks "What brings you here today?" and records the patient's chief complaint - the main reason they came to the hospital.

Data Model

Field	Type	Required	Description
patient_code	string	YES	Reference to patient's unique code
visit_code	string	YES	Reference to visit the unique code
encounter_code	string	YES	Reference to encounter a unique code (nullable)
code	string	YES	Unique identifier for the triage
chief_complaint	text	YES	Primary symptom or problem reported by the patient at the time of the visit
height	number	YES	Value of height of the patient in CM
weight	number	YES	Value of weight of the patient in KG
recorded_at	datetime	YES	Date and time triage was recorded
recorded_by	string	YES	Name of the healthcare provider who recorded the triage
title	string		Position of the healthcare provider

Example

{
  "triages": [
    {
      "visit_code": "V420650",
      "encounter_code": "P25003877",
      "code": "TR250317",
      "chief_complaint": "Periodic fever with chills for 3 days",
      "height": 170,
      "weight": 65,
      "recorded_at": "2025-03-17T09:32:00.000+07:00",
      "recorded_by": "Khun Srey Mom",
      "title": "Nurse"
    }
  ]
}

Vital Signs

Vital signs are like taking a snapshot of how the patient's body is functioning right now. These are the basic measurements that tell healthcare providers if the patient is stable, in distress, or needs immediate attention.

Think of vital signs as the body's "dashboard" - just like a car's dashboard shows speed, fuel level, and engine temperature, vital signs show the body's key functions: heart rate, blood pressure, temperature, breathing rate, and oxygen levels.

Normal Ranges Reference

Vital Sign	Normal Range	Units
Temperature	36.5–37.3 °C	°C
Pulse (Heart Rate)	60–100 beats per minute	/mn
Respiratory Rate	12–20 breaths per minute	/mn
Blood Pressure	Systolic: 90–120 mmHg, Diastolic: 60–80 mmHg	mmHg
Oxygen Saturation (SpO₂)	95–100%	%
Random Glucose Rapid Test	Random: < 140 mg/dL, Fasting: 70–99 mg/dL	mg/dL

Data Model

Field	Type	Required	Description
encounter_code	string	YES	Reference to encounter a unique code
recorded_at	datetime	YES	Date and time vital signs were recorded
recorded_by	string	YES	Name of healthcare provider who recorded the vital signs
title	string	YES	Doctor or nurse
observations	array of objects	YES	Array of vital sign measurements

Observation in Vital Sign

Field	Type	Required	Description
name	string	YES	Name of the vital sign
value	numeric	YES	Measured value

Example

{
  "vital_signs": [
    {
      "encounter_code": "E417001",
      "recorded_at": "2025-03-17T09:40:00.000+07:00",
      "recorded_by": "Khun Srey Mom",
      "title": "Nurse",
      "observations": [
        {
          "name": "Systolic Blood Pressure",
          "value": 135
        },
        {
          "name": "Diastolic Blood Pressure",
          "value": 85
        },
        {
          "name": "Heart Rate",
          "value": 92
        },
        {
          "name": "Temperature",
          "value": 38.7
        },
        {
          "name": "Blood Oxygen",
          "value": 97
        }
      ]
    }
  ]
}

Medical History

Medical history is like reading the previous chapters of the patient's health story. Before treating someone, doctors need to know: What health problems have they had before? What medications are they taking? Are they allergic to anything? What runs in their family?

This information helps doctors understand the full picture and make better decisions about treatment.

History Categories

Category	What It Includes
Current Illness	What's happening now - symptoms, when they started, what makes them better or worse
Current Medications	What medicines the patient is taking right now
Past Medical History	Previous illnesses, hospitalizations, chronic conditions
Past Surgical History	Any surgeries the patient has had
Allergies	Things the patient is allergic to (foods, medicines, etc.)
Immunizations	Vaccinations the patient has received
Family History	Health problems that run in the family
Social History	Lifestyle factors like smoking, drinking, occupation

Data Model

Field	Type	Required	Description
patient_code	string	YES	Reference to the patient unique code
visit_code	string	YES	Reference to visit the unique code
encounter_code	text	YES	Reference to encounter a unique code
name	string	YES	Name of the condition
value	array of strings	YES	Array of value in string of the condition

Example

{
  "medical_histories": [
    {
      "patient_code": "P25003877",
      "visit_code": "V420650",
      "encounter_code": "E417001",
      "name": "Current Illness History",
      "value": [
        "Patient reports high fever with chills occurring every 48 hours, accompanied by headache and joint pain. Symptoms started 3 days ago after returning from a trip to Mondulkiri province."
      ]
    },
    {
      "patient_code": "P25003877",
      "visit_code": "V420650",
      "encounter_code": "E417001",
      "name": "Allergies",
      "value": ["Penicillin", "Shellfish"]
    },
    {
      "patient_code": "P25003877",
      "visit_code": "V420650",
      "encounter_code": "E417001",
      "name": "Family History",
      "value": ["Mother with diabetes", "Father with hypertension"]
    }
  ]
}

Physical Examination

Physical examination is where the doctor becomes a detective, using their senses to gather clues about what's wrong with the patient. They look, listen, feel, and sometimes smell to understand what's happening inside the patient's body.

This is hands-on medicine - the doctor examines different parts of the body systematically, from head to toe, looking for signs of illness or injury.

Examination Areas

Body System	What Doctors Check
General Appearance	How the patient looks overall - alert, distressed, well-nourished
Head & Neck	Eyes, ears, nose, throat, neck lymph nodes
Heart & Lungs	Heart sounds, breathing sounds, chest movement
Abdomen	Belly tenderness, organ size, bowel sounds
Skin	Rashes, color changes, wounds
Nervous System	Reflexes, coordination, mental status
Muscles & Joints	Strength, movement, swelling

Data Model

Field	Type	Required	Description
patient_code	string	YES	Reference to patient unique code
visit_code	string	YES	Reference to visit unique code
encounter_code	string		Reference to encounter unique code
name	string	YES	Name for the physical assessment point
value	various	YES	Value of the assessment result
value_type	string	YES	Type of Value
value_unit	string		Measurement unit represent the value

Example

{
  "physical_examinations": [
    {
      "patient_code": "P25003877",
      "visit_code": "V420650",
      "encounter_code": "E417001",
      "name": "General Appearance",
      "value": "Patient appears ill and tired, with intermittent shivering",
      "value_type": "text",
      "value_unit": null
    },
    {
      "patient_code": "P25003877",
      "visit_code": "V420650",
      "encounter_code": "E417001",
      "name": "Skin",
      "value": "Warm to touch, slightly yellow color (jaundiced), no rash visible",
      "value_type": "text",
      "value_unit": null
    }
  ]
}

Laboratories

Laboratory tests are like sending samples to a detective lab to uncover hidden clues about the patient's condition. Blood, urine, and other samples are analyzed to reveal information that can't be seen with the naked eye.

These tests can confirm what doctors suspect, rule out certain conditions, or sometimes reveal unexpected findings that change the entire treatment plan.

Data Model

Field	Type	Required	Description
patient_code	string	YES	Reference to patient unique code
visit_code	string	YES	Reference to visit unique code
encounter_code	string		Reference to encounter unique code
request_code	string	YES	Unique code represents the lab request
requested_at	datetime	YES	Date and time laboratory were requested
requested_by	string	YES	Name of doctor who requested the laboratory
title	string		Name of doctor
results	array of objects	YES	Array of laboratory objects

Result Model

Field	Type	Required	Description
name	string	YES	The item of lab result
category	string	YES	Category that lab result fall under (e.g. biochemistry, hematology)
value	various	YES	Measured value
value_type	string	YES	Type of value
value_unit	string	YES	Unit of measurement
reference_range	string	YES	Normal range for the measurement
interpretation	string	YES	Interpretation of the result
verified_at	datetime	YES	Date and time of doctor who verified
verified_by	string	YES	Name of healthcare provider who verified
recorded_at	datetime	YES	Date and time of doctor who recorded
recorded_by	string	YES	Name of healthcare provider who recorded

Example

{
  "laboratories": [
    {
      "patient_code": "P25003877",
      "visit_code": "V420650",
      "encounter_code": "E417001",
      "request_code": "L7001",
      "requested_at": "2025-03-17T10:30:00.000+07:00",
      "requested_by": "Dr. Chhun Sovannarith",
      "title": "Doctor",
      "results": [
        {
          "name": "Malaria Blood Smear",
          "category": "Parasitology",
          "value": "Positive for P. falciparum",
          "value_type": "string",
          "value_unit": null,
          "reference_range": "Negative",
          "interpretation": "Positive - Malaria parasites found",
          "verified_by": "Dr. Meas Chenda",
          "recorded_by": "Lab Tech Chandaravuth"
        },
        {
          "name": "Hemoglobin",
          "category": "Hematology",
          "value": 11.2,
          "value_type": "float",
          "value_unit": "g/dL",
          "reference_range": "13.5-17.5",
          "interpretation": "Low - Below normal range",
          "verified_by": "Dr. Meas Chenda",
          "recorded_by": "Lab Tech Chandaravuth"
        }
      ]
    }
  ]
}

Imageries

Imageries represent medical imaging studies performed on a patient, such as X-rays, ultrasounds, CT scans, and MRIs. These diagnostic tools allow healthcare providers to visualize internal structures of the body to aid in diagnosis and treatment planning.

Data Model

Field	Type	Required	Description
patient_code	string	YES	Reference to patient's unique code
visit_code	string	YES	Reference to visit the unique code
encounter_code	string		Reference to encounter a unique code
request_code	string	YES	Unique code represents the lab request
requested_at	datetime	YES	Date and time of the imagery requested
requested_by	string	YES	Name of the healthcare provider who requested the imagery
title	string	YES	Name of doctor
results	array of objects	YES	Array of imagery objects

Result Model

Field	Type	Required	Description
name	string	YES	The item of the imaging result
category	string	YES	Category that imaging falls under (e.g. radiology, … )
images	array of strings	YES	Measured value
result	string	YES	Full result of the imagery
conclusion	string	YES	Summary of the result
verified_at	datetime	YES	Date and time that the sample was verified
verified_by	string	YES	Name of healthcare provider who verified the sample
recorded_at	datetime	YES	Date and time results were recorded
recorded_by	string	YES	Name of the healthcare provider who recorded the result

Diagnosis

Diagnosis is the moment when all the pieces of the puzzle come together. After listening to the patient, examining them, and reviewing test results, the doctor determines what's wrong. This is the "answer" to the medical mystery.

Sometimes there's one clear diagnosis, sometimes there are multiple conditions, and sometimes doctors need to consider several possibilities (differential diagnosis).

Diagnosis Types

Type	When It's Used
Primary	The main reason for this hospital visit
Secondary	Other conditions that also need attention
Differential	Possible diagnoses being considered
Admission	Initial diagnosis when patient arrives
Discharge	Final diagnosis when patient leaves

Data Model

Field	Type	Required	Description
patient_code	string	YES	Reference to patient unique code
visit_code	string	YES	Reference to visit unique code
encounter_code	string		Reference to encounter unique code
diagnosis_type	string	YES	Name of diagnosis type as above table
diagnosis_code	string	YES	ICD-10 code for the diagnosis
diagnosis_name	string	YES	Name of the diagnosis
diagnosis_description	string		Detailed description of the diagnosis
diagnosed_at	datetime	YES	Date and time of diagnosis
diagnosed_by	string	YES	Name of healthcare provider who made the diagnosis
title	string		Position of the healthcare provider (doctor or nurse)

Example

{
  "diagnoses": [
    {
      "patient_code": "P25003877",
      "visit_code": "V420650",
      "encounter_code": "E317001",
      "diagnosis_type": "Primary",
      "diagnosis_code": "B50.9",
      "diagnosis_name": "Plasmodium falciparum malaria, unspecified",
      "diagnosis_description": "Malaria caused by P. falciparum parasites, confirmed by blood smear",
      "diagnosed_at": "2025-03-17T10:05:00.000+07:00",
      "diagnosed_by": "Dr. Chhun Sovannarith"
    }
  ]
}

SOAP

SOAP (Subjective, Objective, Assessment, Plan) is a structured documentation method used by healthcare providers to organize clinical notes during patient encounters.

Data Model

Field	Type	Required	Description
encounter_code	string	YES	Reference to encounter unique code
subjective	text		Patient's reported symptoms and feelings
objective	text		Provider's objective
assessment	text		Provider's assessment of the patient situation
evaluation	text		Provider's summary or evaluation regarding the assessment
plan	text		Plan for treatment or next steps
code	string		Unique identifier for the SOAPs
recorded_at	datetime		Date and time SOAPs was written
recorded_by	string		Name of healthcare provider who wrote the SOAPs
title	string		Position of the healthcare provider (doctor or nurse)

Prescriptions

Updated on 2026-03-06

Prescriptions are the doctor's treatment plan written down as specific medications. After diagnosing the problem, the doctor decides which medicines will help the patient get better.

Some medications are given at the hospital during treatment, while others are prescribed for the patient to take at home. Each prescription includes detailed instructions on how much to take, when to take it, and for how long.

NOTE

• Medication dispensed during hospitalization: Requires encounter_code linking to progress_notes, outpatient, inpatient, surgery, or emergency
• Medication dispensed for home use: Requires encounter_code to be null

Data Model

Field	Type	Required	Description
patient_code	string	YES	Reference to the patient's unique code
visit_code	string	YES	Reference to visit the unique code
encounter_code	string		Reference to encounter a unique code
code	string	YES	Unique identifier for the prescription
prescribed_at	datetime	YES	Date and time the prescription was written
prescribed_by	string	YES	Name of healthcare provider who wrote the prescription
title	string		Position, whether doctor or nurse, or else
medications	array of objects	YES	Array of medications is prescribed

Medication Model

Field	Type	Required	Description
medicine_code	string	YES	Unique identifier for the medication
medicine_name	string	YES	Name of the medicine
strength	string		Strength of the medicine
method	string	YES	Method of administration
unit	string	YES	Unit of measurement
morning	numeric		Morning dose
afternoon	numeric		Afternoon dose
evening	numeric		Evening dose
night	numeric		Night dose
days	integer	YES	Duration of prescription in days
interval	string		Interval between doses
note	text		Additional notes or instructions

NOTE

• If no interval is provided, morning, afternoon, evening, night should be presented
• strength is required if it is not presented in medicine_name

Dispense Model

Field	Type	Required	Description
unit	string	YES	Unit of measurement (e.g., "Boxes", "Bottles", "Tablets")
quantity	integer	YES	Total amount dispensed to the patient

NOTE

Dispense: Specifies the total quantity of the drug provided to the patient.

Example

{
  "prescriptions": [
    {
      "patient_code": "P25003877",
      "visit_code": "V420650",
      "encounter_code": "E417001",
      "code": "RX20250317001",
      "prescribed_at": "2025-03-17T10:10:00.000+07:00",
      "prescribed_by": "Dr. Chhun Sovannarith",
      "title": "Doctor",
      "medications": [
        {
          "medicine_code": "MED001",
          "medicine_name": "Artemether-Lumefantrine",
          "strength": "20/120mg",
          "method": "Oral",
          "unit": "Tablet",
          "morning": 4,
          "afternoon": 0,
          "evening": 4,
          "night": 0,
          "days": 3,
          "interval": null,
          "note": "Take with food. Complete the full course.",
          "dispense": {
            "quantity": 1,
            "unit": "Boxes"
          }
        },
        {
          "medicine_code": "MED002",
          "medicine_name": "Paracetamol",
          "strength": "500mg",
          "method": "Oral",
          "unit": "Tablet",
          "morning": 0,
          "afternoon": 0,
          "evening": 0,
          "night": 0,
          "days": 5,
          "interval": "8 hours",
          "note": "Take only when you have fever or pain.",
          "dispense": {
            "quantity": 1,
            "unit": "Boxes"
          }
        }
      ]
    }
  ]
}

Invoices

Invoices are the financial record of the patient's visit - what services were provided and what they cost. This includes everything from consultation fees to laboratory tests to medications.

In Cambodia's healthcare system, many patients are covered by health insurance programs (like HEF or NSSF), so the invoice also tracks what the patient pays versus what the insurance covers.

Data Model

Field	Type	Required	Description
patient_code	string	YES	Reference to patient unique code
visit_code	string	YES	Reference to visit unique code
encounter_code	string		Reference to encounter unique code
code	string	YES	Invoice identifier
payment_type	string	YES	Type of payment
invoice_date	datetime	YES	Invoice date
total	number	YES	Total amount
created_at	datetime	YES	Creation timestamp
updated_at	datetime		Update timestamp
cashier	string	YES	Name of cashier

Service Model

Field	Type	Required	Description
invoice_code	string	YES	Invoice identifier
service_code	string	YES	Code identify the provided service
service_name	string	YES	Name of the service provided
service_category	string	YES	Category name of the service
price	number	YES	Unit price
quantity	number		Number of service provided
payment	number		Payment received from patient
paid	boolean		Payment status
discount_type	string		String whether in percentage or amount
discount	number		Discount amount or percentage

Medication Model

Field	Type	Required	Description
invoice_code	string	YES	Invoice identifier
medicine_code	string	YES	Code identifies the provided service
medicine_name	string	YES	Name of the service provided
quantity	number	YES	Number of medicines provided
price	number	YES	Unit price
payment	number		Payment received from patient
paid	boolean		Payment status
discount_type	string		String whether in percentage or amount
discount	number		Discount amount or percentage

Example

{
  "invoices": [
    {
      "patient_code": "P25003877",
      "visit_code": "V420650",
      "encounter_code": "E417001",
      "code": "INV20250317001",
      "payment_type": "HEF",
      "invoice_date": "2025-03-17T11:00:00.000+07:00",
      "total": 45000,
      "cashier": "Sok Kunthea",
      "services": [
        {
          "service_code": "SRV001",
          "service_name": "Blood Smear for Malaria",
          "service_category": "Laboratory Test",
          "price": 15000,
          "payment": 0,
          "paid": false,
          "discount": 15000
        }
      ],
      "medications": [
        {
          "medicine_code": "MED001",
          "medicine_name": "Artemether-Lumefantrine 20/120mg",
          "quantity": 24,
          "unit": "Tablet",
          "price": 1250,
          "payment": 0,
          "paid": false,
          "discount": 30000
        }
      ]
    }
  ]
}

Referrals

Sometimes a patient needs care that the current hospital can't provide - maybe they need specialized treatment, advanced equipment, or a higher level of care. When this happens, the patient is "referred" to another healthcare facility.

Referrals are like passing the patient's story to the next chapter, but at a different hospital. All the information about their condition, treatment so far, and why they need to be transferred is carefully documented.

Data Model

Field	Type	Description
referred_from	object	Information about the referring facility
referred_to	object	Information about the receiving facility

Detail Model

Field	Type	Required	Description
code	string	YES	Unique identifier for the referral
referral_number	string	YES	Unique reference number for the referral
transportation	string	YES	Mode of transportation
reason	string	YES	Reason for referral
has_called	boolean		Whether the receiving facility was called in advance
caretaker_name	string		Name of the person accompanying the patient
caretaker_phone	string		Contact number for the caretaker
referred_by	string		Name of the referring provider
referred_by_phone	string		Contact number for the referring provider
referred_at	datetime		Date and time of referral
received_by	string		Name of the receiving provider
received_by_phone	string		Contact number for the receiving provider
received_at	datetime		Date and time the patient was received
medications	string		Medications that the patient is taking
health_facility	object		Receiving facility / referring facility

Health Facility Model

Field	Type	Required	Description
name	string	YES	Health facility's name
code	string	YES	Health facility's code
label	string		Health facility's label
type	string		Health facility's type

Example

{
  "referrals": {
    "referred_from": null,
    "referred_to": {
      "code": "REF20250317001",
      "referral_number": "HCPP/REF/2025/317",
      "transportation": "Ambulance",
      "health_facility": {
        "name": "Calmette Hospital",
        "code": "121020",
        "label": "National Referral Hospital",
        "type": "Tertiary"
      },
      "reason": "Severe malaria with complications requiring intensive care and specialized treatment not available at this facility",
      "has_called": true,
      "caretaker_name": "Sok Channary (wife)",
      "caretaker_phone": "012345678",
      "referred_by": "Dr. Chhun Sovannarith",
      "referred_at": "2025-03-17T11:30:00.000+07:00",
      "received_by": "Dr. Pich Vothy",
      "received_at": "2025-03-17T12:15:00.000+07:00",
      "medications": "Currently on Artemether-Lumefantrine (1 dose given), IV fluids started"
    }
  }
}

Consultations

A clinical encounter where a patient interacts with a healthcare provider for assessment, advice, or diagnosis, without necessarily receiving a prescription or procedure.

Data Model

Field	Type	Required	Description
consultations	array of strings	NO	Assesses, advises, and guides a patient regarding their health condition.

Example

{
  "consultations": [
    "Review of normal laboratory results and reassurance.",
    "Education on benign nature of tension headaches."
  ]
}

Forms Added in v1.4

Specialized clinical programs and healthcare services often require structured, program-specific records that capture domain-focused assessments, questionnaires, and clinical indicators. The Forms component provides a flexible, standardized structure to record specialized data for programs such as Antenatal Care (ANC), Postnatal Care (PNC), Labor & Delivery, Family Planning & Contraception, Safe Abortion Care, and Child Growth & Physical Examinations.

Each submitted form links directly to its parent visit and encounter via visit_code and encounter_code. The standard form definition is identified by a unique form_code and form_name, while the specific clinical questions, answers, and measurements are encapsulated within the flexible form_data key-value object.

Data Model

Field	Type	Required	Description
visit_code	string	YES	Reference to the visit's unique code
form_code	string	YES	Standard unique identifier for the form definition (e.g., ENTY-000016Z)
form_name	string	YES	Descriptive name of the clinical form (e.g., OPD Contraception, Delivery)
encounter_code	string	YES	Reference to the encounter's unique code
form_data	object	YES	Key-value object containing the specific clinical questions and answers for the form

Standard Form Types

The EMR system supports standard clinical forms across reproductive, maternal, and pediatric health:

Form Name	Form Code	Clinical Scope
OPD Contraception	ENTY-000016Z	Family planning consultations, contraceptive methods chosen/administered, and client history
Delivery	ENTY-0000K15	Labor & delivery summary, obstetrical history, delivery mode, oxytocin administration, and newborn vitality
Abortion	ENTY-0000K1B	Safe abortion care, uterine size, clinical procedure method, and post-abortion contraception uptake
OPD ANC	ENTY-000H014	Antenatal care visit, gestational age, uterine fundal height, and fetal heart rate
OPD PNC	ENTY-000001B2	Postnatal care checkup, postpartum days, maternal danger signs, and infant danger signs
Child Phy-Exam(0-28 Days)	ENTY-00000A8C	Neonatal physical examination within 28 days of birth, APGAR scores, birth weight, and congenital screening
Child Phy-Exam(1M-5Y)	ENTY-00000A9M	Pediatric physical examination (1 month to 5 years), growth tracking, and developmental milestones

Form Data Fields Reference (form_data)

Each clinical form captures specialized fields within the form_data object:

1. OPD Contraception (ENTY-000016Z)

• birth_control_type: Selected contraceptive method or clinical procedure (e.g., Combined Oral Contraceptive (COC), Injectable Contraceptive, Intrauterine Device (IUD), Contraceptive Implant, Condom, Removal of IUD, Insertion of Contraceptive Implant, Contraceptive Implant Follow-up, Removal of Contraceptive Implant, Counseling)
• birth_control_customer_type: Client contraceptive usage status (Past User, First-Time User, Continuing User / Current User)

2. Delivery (ENTY-0000K15)

• maternal_delivery_status: Maternal clinical status during delivery (e.g., normal)
• delivery_number_of_newborn: Total number of newborns delivered
• delivery_number_of_pregnant: Total number of pregnancies (Gravida)
• delivery_number_of_delivery: Total number of viable deliveries (Parity)
• delivery_number_of_miscarriage: Prior spontaneous miscarriages count
• delivery_number_of_abortion: Prior induced abortions count
• delivery_pregnancy_in_weeks: Gestational age in completed weeks
• delivery_at: Timestamp of delivery (ISO 8601 format)
• delivery_type: Delivery procedure type (Normal Vaginal Delivery (NVD), Assisted Vaginal Delivery, Cesarean Section (C-Section))
• delivery_oxytocin_injection: Whether active oxytocin management was administered (Yes / No)
• delivery_oxytocin_injection_date: Timestamp when oxytocin was administered
• delivery_baby_born: Birth outcome status (Live Birth / Stillbirth / Yes)
• delivery_baby_breathing_in_first_minute: Newborn breathing / vitality observation within first minute
• delivery_baby_sex: Biological sex of the infant (Male / Female)
• delivery_breastfeed_in_first_hour: Whether infant was breastfed within the first hour (Yes / No)
• delivery_baby_weight: Birth weight in grams (e.g., 2850)

3. Abortion (ENTY-0000K1B)

• safe_abortion_children_alive: Count of living children
• number_of_miscarriage: Number of prior miscarriages
• number_of_abortion: Number of prior abortions
• pregnancy_test: Pregnancy test confirmation status (e.g., Done)
• problems_upon_arrival: Clinical symptoms or issues upon arrival (e.g., None)
• safe_abortion_uterine_size: Sized uterus in weeks of gestation
• safe_abortion_method: Clinical procedure method (Medical Abortion, Manual Vacuum Aspiration (MVA), Dilation and Evacuation (D&E), Other Methods)
• safe_abortion_is_customer_get_method_before_leave: Whether contraceptive method was provided before leaving (Yes / No)
• type_of_contraceptive_method_received: Contraceptive method received post-abortion (Combined Oral Contraceptive (COC), Injectable Contraceptive, Intrauterine Device (IUD), Contraceptive Implant, Condom, Sterilization)

4. OPD ANC (ENTY-000H014)

• pregnancy_number_of_pregnancies: Total number of pregnancies (Gravida)
• pregnancy_age: Gestational age in weeks
• uterine_height_cm: Symphysis-fundal uterine height in centimeters
• fetal_heart_rate: Fetal heart rate (bpm)
• pregnancy_last_menstrual_period_date: First day of last menstrual period date (YYYY-MM-DD)

5. OPD PNC (ENTY-000001B2)

• pnc_days_after_delivery: Number of days elapsed post-delivery
• pnc_maternal_danger_signs_and_treatment: Observed postpartum maternal danger signs and treatments provided
• pnc_baby_danger_signs_and_treatment: Observed neonatal danger signs and treatments provided

6. Child Physical Examination (0–28 Days) (ENTY-00000A8C)

• pnc_days_after_delivery: Age in days post-delivery
• child_growth_born_weight: Birth weight in grams
• term_or_preterm_birth: Term delivery status
• baby_long_labor: Prolonged labor history
• baby_maternal_fever_at_birth: Maternal fever at delivery
• baby_apgar_one_minute, baby_apgar_five_minutes, baby_apgar_ten_minutes: APGAR assessment values
• baby_born_with_clubfoot: Congenital clubfoot screening (Yes / No)
• difficulty_with_breastfeeding: Feeding difficulties noted
• child_convulsions: Convulsion/seizure assessment
• meconium_passed_within24Hours: Timely meconium evacuation screening (Yes / No)
• child_examination_results: Clinical finds
• child_other_observation_note: Other observation note

7. Child Physical Examination (1M–5Y) (ENTY-00000A9M)

• born_weight: Birth weight in grams
• child_ever_had_severe_health_problems: History of major childhood illnesses
• term_or_preterm_birth: Gestational maturity status at birth
• child_difficult_delivery: History of birth complications
• child_feeding_drinking_difficulty: Feeding or drinking difficulties noted
• child_convulsions: Seizure history
• child_not_toilet_trained_like_peers: Toilet training milestone achieved (Yes / No)
• difficulty_with_breastfeeding: Breastfeeding issues
• child_unable_to_speak_like_peers: Language and speech developmental milestone assessment
• child_unable_to_play_like_peers: Social interaction and play milestone assessment
• child_examination_results: Clinical finds
• child_other_observation_note: Other observation note

Standard Value Mappings & Terminology

Standard observation values used in form fields map directly to national observation value codes (OBVA-...) and international terminology systems (SNOMED CT and LOINC):

Family Planning & Contraception

Field (English / Khmer)	Code	Khmer Value	English Value	Int. Code	System	Concept Name
Birth Control Type វិធីពន្យារកំណើត	OBVA-S000099	ថ្នាំគ្រាប់ស៊ីអូស៊ី	Combined Oral Contraceptive (COC)	7800008	SNOMED CT	Oral contraceptive preparation
	OBVA-00D0097	ថ្នាំចាក់	Injectable Contraceptive	772986005	SNOMED CT	Injectable contraceptive
	OBVA-00P0096	កងដាក់ក្នុងស្បូន	Intrauterine Device (IUD)	78048006	SNOMED CT	Intrauterine device
	OBVA-00W009A	កងដាក់ក្រោមស្បែក	Contraceptive Implant	372756006	SNOMED CT	Contraceptive implant
	OBVA-0000C98	ស្រោមអនាម័យ	Condom	53650009	SNOMED CT	Condom
	OBVA-000159Z	ដោះកងដាក់ក្នុងស្បូន	Removal of IUD	110476007	SNOMED CT	Removal of intrauterine device
	OBVA-00A015B	ការដាក់កងក្នុងដៃ	Insertion of Contraceptive Implant	226922002	SNOMED CT	Insertion of contraceptive implant
	OBVA-000W15C	តាមដានកងដាក់ក្នុងដៃ	Contraceptive Implant Follow-up	310574005	SNOMED CT	Contraceptive implant check
	OBVA-C00015D	ដោះកងដៃចេញ	Removal of Contraceptive Implant	310576007	SNOMED CT	Removal of contraceptive implant
	OBVA-00015VE	ការផ្តល់ប្រឹក្សា	Counseling	409063005	SNOMED CT	Counseling
Customer Type ស្ថានភាពនៃការប្រើប្រាស់វិធីពន្យារកំណើត	OBVA-00001H1	ធ្លាប់ប្រើ	Past User	269785002	SNOMED CT	Past user
	OBVA-0000I10	លើកដំបូង	First-Time User	255225001	SNOMED CT	First
	OBVA-0000I12	ចាស់	Continuing User / Current User	87136001	SNOMED CT	Current user
Post-Abortion Method តើអតិថិជនបានទទួលមធ្យោបាយពន្យារកំណើតប្រភេទណា?	OBVA-S000099	ថ្នាំគ្រាប់ស៊ីអូស៊ី	Combined Oral Contraceptive (COC)	7800008	SNOMED CT	Oral contraceptive preparation
	OBVA-00D0097	ថ្នាំចាក់	Injectable Contraceptive	772986005	SNOMED CT	Injectable contraceptive
	OBVA-00P0096	កងដាក់ក្នុងស្បូន	Intrauterine Device (IUD)	78048006	SNOMED CT	Intrauterine device
	OBVA-00W009A	កងដាក់ក្រោមស្បែក	Contraceptive Implant	372756006	SNOMED CT	Contraceptive implant
	OBVA-0000C98	ស្រោមអនាម័យ	Condom	53650009	SNOMED CT	Condom
	OBVA-0000I9B	បញ្ឈប់កំណើត	Sterilization	69842007	SNOMED CT	Sterilization

Labor & Delivery

Field (English / Khmer)	Code	Khmer Value	English Value	Int. Code	System	Concept Name
Delivery Baby Born ទារកកើត	OBVA-00007ID	កើតរស់	Live Birth	281050002	SNOMED CT	Live birth
	OBVA-00T007C	កើតស្លាប់	Stillbirth	237364002	SNOMED CT	Stillbirth
Delivery Baby Sex ភេទទារក	OBVA-00G007A	ប្រុស	Male	LA2-8	LOINC	Male
	OBVA-00007GB	ស្រី	Female	LA3-6	LOINC	Female
Delivery Type ប្រភេទសម្រាលកូន	OBVA-000B153	សម្រាលធម្មតា	Normal Vaginal Delivery (NVD)	177228005	SNOMED CT	Normal delivery
	OBVA-00R0154	សម្រាលដោយអន្តរាគមន៍	Assisted Vaginal Delivery	1385001	SNOMED CT	Assisted delivery
	OBVA-X000155	សម្រាលដោយវះកាត់	Cesarean Section (C-Section)	11466000	SNOMED CT	Cesarean section

Safe Abortion Methods

Field (English / Khmer)	Code	Khmer Value	English Value	Int. Code	System	Concept Name
Safe Abortion Method មធ្យោបាយរំលូត / វិធីសាស្ត្ររំលូតកូន	OBVA-00H0156	រំលូតដោយថ្នាំ	Medical Abortion	8963000	SNOMED CT	Medical abortion
	OBVA-000157X	រំលូតដោយបូមសុញ្ញាកាស	Manual Vacuum Aspiration (MVA)	236886002	SNOMED CT	Vacuum aspiration of uterus
	OBVA-0001Z58	រំលូតដោយពង្រីកមាត់ស្បូន និងយកចេញ	Dilation and Evacuation (D&E)	236888001	SNOMED CT	Dilation and evacuation of uterus
	OBVA-0000159W	វិធីសាស្ត្រផ្សេងទៀត	Other Methods	74964007	SNOMED CT	Other contraceptive method

Example

{
  "forms": [
    {
      "visit_code": "VIS071315",
      "form_code": "ENTY-000016Z",
      "form_name": "OPD Contraception",
      "encounter_code": "MED062210",
      "form_data": {
        "birth_control_type": "Combined Oral Contraceptive (COC)",
        "birth_control_customer_type": "Past User"
      }
    },
    {
      "visit_code": "VIS071315",
      "form_code": "ENTY-0000K15",
      "form_name": "Delivery",
      "encounter_code": "MED062210",
      "form_data": {
        "maternal_delivery_status": "normal",
        "delivery_number_of_newborn": 1,
        "delivery_number_of_pregnant": 1,
        "delivery_number_of_delivery": 1,
        "delivery_number_of_miscarriage": 0,
        "delivery_number_of_abortion": 0,
        "delivery_pregnancy_in_weeks": 23,
        "delivery_at": "2025-12-19T18:30:00.000+07:00",
        "delivery_type": "Normal Vaginal Delivery (NVD)",
        "delivery_oxytocin_injection": "Yes",
        "delivery_oxytocin_injection_date": "2025-12-19T18:02:00.000+07:00",
        "delivery_baby_born": "Yes",
        "delivery_baby_breathing_in_first_minute": "120",
        "delivery_baby_sex": "Male",
        "delivery_breastfeed_in_first_hour": "Yes",
        "delivery_baby_weight": "2850"
      }
    },
    {
      "visit_code": "VIS071315",
      "form_code": "ENTY-0000K1B",
      "form_name": "Abortion",
      "encounter_code": "MED062210",
      "form_data": {
        "safe_abortion_children_alive": 1,
        "number_of_miscarriage": 2,
        "number_of_abortion": 1,
        "pregnancy_test": "Done",
        "problems_upon_arrival": "None",
        "type_of_contraceptive_method_received": "Contraceptive Implan",
        "safe_abortion_is_customer_get_method_before_leave": "Yes",
        "safe_abortion_uterine_size": 22,
        "safe_abortion_method": "Medical Abortion"
      }
    },
    {
      "visit_code": "VIS071315",
      "form_code": "ENTY-000H014",
      "form_name": "OPD ANC",
      "encounter_code": "MED062210",
      "form_data": {
        "pregnancy_number_of_pregnancies": 14,
        "pregnancy_age": 12,
        "uterine_height_cm": 34,
        "fetal_heart_rate": 120,
        "pregnancy_last_menstrual_period_date": "2025-10-02"
      }
    },
    {
      "visit_code": "VIS071315",
      "form_code": "ENTY-000001B2",
      "form_name": "OPD PNC",
      "encounter_code": "MED062210",
      "form_data": {
        "pnc_days_after_delivery": 14,
        "pnc_maternal_danger_signs_and_treatment": "None",
        "pnc_baby_danger_signs_and_treatment": "None"
      }
    },
    {
      "visit_code": "VIS071315",
      "form_code": "ENTY-00000A8C",
      "form_name": "Child Phy-Exam(0-28 Days)",
      "encounter_code": "MED062210",
      "form_data": {
        "pnc_days_after_delivery": 14,
        "child_growth_born_weight": 4300,
        "baby_maternal_fever_at_birth": "",
        "baby_long_labor": "",
        "term_or_preterm_birth": "",
        "baby_apgar_one_minute": "113",
        "baby_apgar_ten_minutes": "121",
        "baby_apgar_five_minutes": "111",
        "baby_born_with_clubfoot": "No",
        "difficulty_with_breastfeeding": "",
        "child_convulsions": "",
        "meconium_passed_within24Hours": "No",
        "child_examination_results": "",
        "child_other_observation_note": ""
      }
    },
    {
      "visit_code": "VIS071315",
      "form_code": "ENTY-00000A9M",
      "form_name": "Child Phy-Exam(1M-5Y)",
      "encounter_code": "MED062210",
      "form_data": {
        "born_weight": 4300,
        "child_ever_had_severe_health_problems": "",
        "term_or_preterm_birth": "",
        "child_difficult_delivery": "",
        "child_feeding_drinking_difficulty": "No",
        "child_convulsions": "No",
        "child_not_toilet_trained_like_peers": "Yes",
        "difficulty_with_breastfeeding": "No",
        "child_unable_to_speak_like_peers": "",
        "child_unable_to_play_like_peers": "",
        "child_examination_results": "",
        "child_other_observation_note": ""
      }
    }
  ]
}

---

Summary

Each component tells part of the patient's healthcare story. When connected together through their unique codes, they create a complete picture of the patient's journey from arrival to discharge, including all the care, tests, treatments, and outcomes along the way.