1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1

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The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Comment.gif Antepartum History and Physical Specification 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1

The Antepartum History and Physical contains a record of the initial History and Physical usually performed during the initial visit.


Format Code

The XDSDocumentEntry format code for this content is urn:ihe:pcc:apr:handp:2008

Parent Template

This document is an instance of the History and Physical template.

LOINC Code

The LOINC code for this document is 34117-2 HISTORY AND PHYSICAL

Standards
CDAR2 HL7 CDA Release 2.0
CCD ASTM/HL7 Continuity of Care Document
CDTHP CDA for Common Document Types History and Physical Notes (DSTU)
Data Element Index
Data Element CDA Section Comments
Header Header
Chief Complaint Chief Complaint
Pregnancy History Pregnancy History Summary (Gravida Para Abortus) and detailed history of pregnancies
Medical History History of Past Illness Exclude social and family history (included in other sections)
Medical History - Tobacco, Alcohol, Drugs Social History
Medical History - Relevant Family History Family History
Medications Medications
Allergies Allergies and Other Adverse Reactions Section
Menstrual History/Symptoms Since LMP Review of Systems
Genetic Screening/Teratology Counseling Family History
Infection History History of Infection
Initial Physical Examination Physical Examination
Vital Signs Vital Signs subsection of Physical Examination
Diagnostic Findings This section is required by CDA4CDT H&P - The requirement of the APR specification is to have the antepartum specific laboratory results in the APR Laboratory document. However, this type of data may also be included here.
Specification
Data Element Name Opt Template ID
Spouse R 1.3.6.1.4.1.19376.1.5.3.1.2.4.1
Natural Father of Fetus R 1.3.6.1.4.1.19376.1.5.3.1.2.4.2
Enthnicity
The enthnicity of the patient should be recorded
R2
Chief Complaint R 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1
History of Present Illness R 1.3.6.1.4.1.19376.1.5.3.1.3.4
History of Past Illness
This section is the same as it is for History and Physical, however it SHALL contain entries and SHOULD use codes as specified in the Antepartum History and Physical History of Past Illness Value Set. A negative diagnosis SHALL be recorded with the use of the negation indicator attribute. If the data is not present or not available within the system no entry is required.
R 1.3.6.1.4.1.19376.1.5.3.1.3.8
History of Infection
This section SHALL contain coded entries for infection history and SHOULD use the codes as specified in the Antepartum Infection History Value Set.
R 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1
Pregnancy History
This section SHALL use the existing Pregnancy History Section and follow all constraints as specified therein.
R 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4
Social History
This section is the same as it is for History & Physical, however it SHALL contain coded entries and SHOULD use the codes specified in the Antepartum Social History Value Set. If the data is not present or not available within the system no entries are required.
R 1.3.6.1.4.1.19376.1.5.3.1.3.16
Coded Family Medical History
This section is the same as it is for History & Physical, however it SHALL contain Genetic Screening and Teratology Counseling information as specified in the Antepartum Family History and Genetic Screening Value Set. If the data is not present or not available within the system no entries are required.
R 1.3.6.1.4.1.19376.1.5.3.1.3.15
Review of Systems
This section is the same as it is for History & Physical, however it SHALL include organizers for Menstrual History and MAY include entries for general review of systems data. The Menstrual History entries SHOULD use the codes specified in the Antepartum Menstrual History Value Set. The section code value for the Menstrual History organizer SHALL be '49033-4'. The codeSystem is '2.16.840.1.113883.6.1'. The codeSystemName is 'LOINC'.
R 1.3.6.1.4.1.19376.1.5.3.1.3.18
Physical Examination
This section is the same as it is for History & Physical, and if Vital Signs data are present it SHALL include a Vital Signs subsection.
R 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
Vital Signs
If Vital Signs data are present they SHALL be included as a subsection of Physical Examination.
C 1.3.6.1.4.1.19376.1.5.3.1.3.25

Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below. A CDA Document may conform to more than one template. This content module inherits from the History and Physical content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Antepartum History and Physical Document
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4'/>
 <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1'/> <id root=' ' extension=' '/> <code code='34117-2' displayName='HISTORY AND PHYSICAL' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>Antepartum History and Physical</title> <effectiveTime value='20190920012005'/> <confidentialityCode code='N' displayName='Normal' codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' /> <languageCode code='en-US'/>  : <component><structuredBody>  <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/> <!-- Required Chief Complaint Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/> <!-- Required History of Present Illness Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/> <!-- Required History of Past Illness Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1'/> <!-- Required History of Infection Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/> <!-- Required Pregnancy History Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/> <!-- Required Social History Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/> <!-- Required Coded Family Medical History Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/> <!-- Required Review of Systems Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/> <!-- Required Physical Examination Section content --> </section> </component>
 <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/> <!-- Conditional Vital Signs Section content --> </section> </component>
    </structuredBody></component> </ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Antepartum History and Physical can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4"]'>
     Error: The parent template identifier for Antepartum History and Physical is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "34117-2"]'>
     Error: The document type code of a Antepartum History and Physical must be 34117-2
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.4.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Spouse Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.4.2"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Natural Father of Fetus Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = ""]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Antepartum History and Physical Document should contain a(n) Enthnicity Entry.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Chief Complaint Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) History of Present Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) History of Past Illness Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) History of Infection Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Pregnancy History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Coded Family Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Antepartum History and Physical Document must contain a(n) Physical Examination Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> 
     <!-- Manually verify condtional elements -->
     Manual: This Antepartum History and Physical Document does not contain a(n) Vital Signs Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 
   </assert> 
 </rule>
</pattern>