Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4"
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+ | == Past Medical History Section== | ||
+ | {| border=1 cellspacing=0 | ||
+ | |- | ||
+ | !style='background-color:#cfcfcf;'|TemplateID | ||
+ | | colspan=2|2.16.840.1.113883.10.20.2.9 - this is a CDA4CDT OID - is it ok to reference here? or do we need IHE OID? | ||
+ | |- | ||
+ | !style='background-color:#cfcfcf;'|Parent Template | ||
+ | | colspan=2| | ||
+ | |- | ||
+ | !style='background-color:#cfcfcf;'|General Description | ||
+ | |colspan=2|The Past Medical History section SHALL contain exactly one and SHALL NOT contain more than one Past Medical History section (templateId 2.16.840.1.113883.10.20.2.9), it SHALL contain a narrative block, and it SHOULD contain clinical statements. This section references what has been defined in CDA4CDT History & Physical Note. | ||
+ | |- style='background-color:#cfcfcf;' | ||
+ | !LOINC Code | ||
+ | !Opt | ||
+ | !Description | ||
+ | |- | ||
+ | |11348-0 | ||
+ | |align='center'|R | ||
+ | |Past Medical History | ||
+ | |} | ||
+ | |||
+ | |||
+ | |||
+ | ==== Sample Past Medical History Section ==== | ||
+ | <pre> | ||
+ | <component> | ||
+ | <section> | ||
+ | <templateId root= 2.16.840.1.113883.10.20.2.9 /> | ||
+ | <code code='11348-0' codeSystem="2.16.840.1.113883.6.1" displayName='HISTORY OF PAST ILLNESS'/> | ||
+ | <title>PAST MEDICAL HISTORY</title> | ||
+ | <text>Text as described above</text> | ||
+ | </section> | ||
+ | </component> | ||
+ | </pre> | ||
+ | === entry === | ||
+ | Description of the entry element. |
Revision as of 15:45, 24 April 2008
This is a draft of a History and Physical Template. This draft is a work in progress, not the official supplement or profile.
The intention of this work is to provide a parent template for the History and Physical specifications needed in Antepartum Summary Forms A&B (History and Physical).
Document Specification
Section | Opt | Template ID | Comments |
---|---|---|---|
Header |
R | not sure how to do this section | |
Reason for Visit/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 | |
Past Medical History |
R | 1.3.6.1.4.1.19376.1.5.3.1.xyz | new section - see below |
Social History |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.16 | |
Family History |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.14 | |
Review of Systems |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.18 | |
Physical Examination |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.24 |
Past Medical History Section
TemplateID | 2.16.840.1.113883.10.20.2.9 - this is a CDA4CDT OID - is it ok to reference here? or do we need IHE OID? | |
---|---|---|
Parent Template | ||
General Description | The Past Medical History section SHALL contain exactly one and SHALL NOT contain more than one Past Medical History section (templateId 2.16.840.1.113883.10.20.2.9), it SHALL contain a narrative block, and it SHOULD contain clinical statements. This section references what has been defined in CDA4CDT History & Physical Note. | |
LOINC Code | Opt | Description |
11348-0 | R | Past Medical History |
Sample Past Medical History Section
<component> <section> <templateId root= 2.16.840.1.113883.10.20.2.9 /> <code code='11348-0' codeSystem="2.16.840.1.113883.6.1" displayName='HISTORY OF PAST ILLNESS'/> <title>PAST MEDICAL HISTORY</title> <text>Text as described above</text> </section> </component>
entry
Description of the entry element.