Clinical Record Summary
A Pragmatic, internationally recognized summary for safe handover at discharge. Built on HL7® FHIR® IPS and aligned to Malaysia’s MY-Core profiles.
For technical details, see the SI-LAB FHIR Implementation Guide and MY-Core profiles
Why start with Clinical Record Summary?
The Clinical Record Summary adapts the HL7 International Patient Summary (IPS) within Malaysia’s context.
It utilizes Malaysia Core profiles to meet local requirements while also declaring conformance to the official IPS profiles.
This dual-profile approach ensures that the same resources satisfy both local and international requirements without duplicating existing models for future scalability.
Scenarios of use:
Hospital Discharge – summary generated when a patient leaves an inpatient facility.
Referral – a concise snapshot of when a patient is referred between providers or institutions.
Cross-border ready
IPS is globally recognized, making information portable across providers and jurisdictions.
Clinically focused
Centers on essentials for safety at discharge: conditions, meds, allergies, procedures, results, immunization
Practical first step
Small, high-value, scope that builds momentum for wider exchange (referrals, claims, registries.
Alignment with MY-Core: The IPS structure/content is implemented using MY-Core resource profiles for local identifiers, code bindings, and must-support elements.
Scope and Purpose
Domestic interoperability
Aligns with Malaysia Core (identifiers, vocabularies, extensions).
International interoperability
Aligns with IPS, allowing the same summary to be exchanged across borders.
Safety
Ensures critical patient information (problems, allergies, medications) is consistently available.
FHIR Resources
Primary resources
- Patient
- Encounter
- Composition (IPS)
- AllergyIntolerance
- MedicationStatement
- Condition (Comorbid)
Additional (as applicable)
- Immunization
- ServiceRequest
- DiagnosticReport
- Observation (vitals/labs)
- Procedure
- DocumentReference (PDF/HTML)
Technical rails
- FHIR R4
- IPS Implementation Guide
- MY-Core profiles
- Terminology server (Smile CDR)
- Validation rulesets
Expected outcomes
Safer, faster handovers
Clinicians receive a consistent summary at discharge, reducing omissions and follow-up calls.
Portable records
Patients can be referred or continue care across facilities with a summary that others can read and validate.
Lower integration cost
Common profiles, shared terminology, and a ready sandbox reduce engineering cycles.
Procurement-ready signals
Objective validation and conformance reports support vendor selection and scale-up plans.
TIME TO FIRST
EXCHANGE
10 days
VALIDATION
PASS RATE
90 %
IPS SECTION
COMPLETENESS
95 %
STAKEHOLDER
SATISFACTION
85 %
What SI-LAB provides
Sandbox & sample data
Public sandbox endpoints with sample records to explore the IPS flow.
Validation & reports
Automates checks for profile conformance and terminology, plus human review where needed.
Implementation guide
Step-by-step profiles, examples, and search parameters aligned to MY-Core.
Reference server
Standards-based server (SmileCDR) for testing, terminology, and validation APIs.
Support & office hours
Weekly touchpoints for blockers; sample payloads and Postman collections.
Reference server
Standards-based server (SmileCDR) for testing, terminology, and validation APIs.
Pilot plan (4 weeks)
WEEK 0-1
Sandbox & sample data
Public sandbox endpoints with sample records to explore the IPS flow.
WEEK 2
Validation & reports
Automates checks for profile conformance and terminology, plus human review where needed.
WEEK 3
Implementation guide
Step-by-step profiles, examples, and search parameters aligned to MY-Core.
WEEK 4
Reference server
Standards-based server (SmileCDR) for testing, terminology, and validation APIs.
What you’ll see in a demo
FAQ
Is this production or a sandbox?
This is a standards interoperability lab (sandbox) used to prove readiness and de-risk go-live.
Which standards are used?
HL7 FHIR R4, IPS Implementation Guide, and MY-Core profiles for local alignment.
Do we need new software to start?
No. Vendors can integrate from existing systems using standard FHIR APIs and our examples.
What do we get at the end?
A validation report, improvement recommendations, and a completion certificate.
CONTACT US
Share your email and any remarks, feedback, a demo request, or a meetup suggestion. We’ll respond with the next steps.
Other ways to reach us
Direct Email
contact@silab.my
pilot@silab.my
Office Hours
Wednesday, 3-4 pm MYT (virtual)
Meeting Location
DHM, Kuala Lumpurpilot@silab.my