Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4"
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||R || 1.3.6.1.4.1.19376.1.5.3.1.xyz ||new section - see below | ||R || 1.3.6.1.4.1.19376.1.5.3.1.xyz ||new section - see below | ||
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− | ||R || | + | ||R || 1.3.6.1.4.1.19376.1.5.3.1.3.19 || |
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− | |Allergies <br/> | + | |[[1.3.6.1.4.1.19376.1.5.3.1.3.13 | Allergies]] <br/> |
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− | |Vital Signs <br/> | + | |[[1.3.6.1.4.1.19376.1.5.3.1.3.25 | Vital Signs]]<br/> |
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|[[1.3.6.1.4.1.19376.1.5.3.1.3.18 | Review of Systems]]<br/> | |[[1.3.6.1.4.1.19376.1.5.3.1.3.18 | Review of Systems]]<br/> | ||
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|Diagnostic Findings<br/> | |Diagnostic Findings<br/> | ||
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− | |Assessment and Plan<br/> | + | |[[1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 | Assessment and Plan]]<br/> |
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Revision as of 18:23, 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 | |
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 |
Medications |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.19 | |
Allergies |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.13 | |
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 | |
Vital Signs |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.25 | |
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 | |
Diagnostic Findings |
R | Lab results and other findings - need to add IHE section? | |
Assessment and Plan |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5 |
Past Medical History Section
TemplateID | 2.16.840.1.113883.10.20.2.9 - this is an HL7 OID - do we need an IHE OID? | |
---|---|---|
Parent Template | ||
General Description | The past medical history section SHALL contain a narrative description of the patient's medical history. | |
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.