Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4"
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− | + | <!-- Chief Complaint --> | |
<component> | <component> | ||
<section> | <section> | ||
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</component> | </component> | ||
− | + | <!-- History of Present Illness --> | |
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<component> | <component> | ||
<section> | <section> |
Revision as of 10:31, 25 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 and Other Adverse Reactions Section |
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 | |
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 | |
Vital Signs |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.25 | |
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 |
Sample IHE History and Physical
<ClinicalDocument> <component> <structuredBody> <!-- Chief Complaint --> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/> <id root=' ' extension=' '/> <code code='10154-3' displayName='CHIEF COMPLAINT' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> </section> </component> <!-- History of Present Illness --> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/> <id root=' ' extension=' '/> <code code='10164-2' displayName='HISTORY OF PRESENT ILLNESS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> </section> </component> <!-- Past Medical History --> <component> <section> <templateId root='2.16.840.1.113883.10.20.2.9'/> <code code='11348-0' displayName='HISTORY OF PAST ILLNESS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>PAST MEDICAL HISTORY</title> <text> Text as described above </text> </section> </component> <!-- Medications --> <component> <section> <templateId root='2.16.840.1.113883.10.20.1.8'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/> <id root=' ' extension=' '/> <code code='10160-0' displayName='HISTORY OF MEDICATION USE' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> <entry> : <!-- Required Medications element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/> : </entry> </section> </component> <!-- Allergies--> <component> <section> <templateId root='2.16.840.1.113883.10.20.1.2'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/> <id root=' ' extension=' '/> <code code='48765-2' displayName='Allergies, adverse reactions, alerts' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> <entry> : <!-- Required Allergies and Intolerances Concern element --> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.3'/> : </entry> </section> </component> <!-- Social History --> <component> <section> <templateId root='2.16.840.1.113883.10.20.1.15'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/> <id root=' ' extension=' '/> <code code='29762-2' displayName='SOCIAL HISTORY' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> </section> </component> <!-- Family History --> <component> <section> <templateId root='2.16.840.1.113883.10.20.1.4'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/> <id root=' ' extension=' '/> <code code='10157-6' displayName='HISTORY OF FAMILY MEMBER DISEASES' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> </section> </component> <!-- Review of Systems --> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/> <id root=' ' extension=' '/> <code code='10187-3' displayName='REVIEW OF SYSTEMS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> </section> </component> <!-- Physical Examination --> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/> <id root=' ' extension=' '/> <code code='29545-1' displayName='PHYSICAL EXAMINATION' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> </section> </component> <!-- Vital Signs --> <component> <section> <templateId root='2.16.840.1.113883.10.20.1.16'/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/> <id root=' ' extension=' '/> <code code='8716-3' displayName='VITAL SIGNS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> </section> </component> <!-- Diagnostic Findings --> <!-- Assessment and Plan --> <component> <section> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5'/> <id root=' ' extension=' '/> <code code='X-AANDP' displayName='ASSESSMENT AND PLAN' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <text> Text as described above </text> </section> </component> </structuredBody> </component> </ClinicalDocument>
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' displayName='HISTORY OF PAST ILLNESS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>PAST MEDICAL HISTORY</title> <text>Text as described above</text> </section> </component>
entry
Description of the entry element.