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==== Sample IHE History and Physical ==== | ==== Sample IHE History and Physical ==== | ||
<pre> | <pre> | ||
| + | |||
<ClinicalDocument> | <ClinicalDocument> | ||
<component> | <component> | ||
<structuredBody> | <structuredBody> | ||
| − | + | ||
<!-- Chief Complaint --> | <!-- 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 --> | <!-- 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> | |
| − | |||
| − | |||
| − | |||
| − | + | <!-- Resolved Problems --> | |
| − | + | <component> | |
| − | + | <section> | |
| − | + | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.8"/> | |
| − | + | <id root=" " extension=" "/> | |
| − | + | <code code="11348-0" displayName="HISTORY OF PAST ILLNESS" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | |
| − | + | <text>Text as described above</text> | |
| − | + | <entry>: | |
| − | + | <!-- Required Problem Concern Entry element --> | |
| − | + | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.2"/>:</entry> | |
| − | + | </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 --> | |
| + | <component> | ||
| + | <section> | ||
| + | <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.27"/> | ||
| + | <id root=" " extension=" "/> | ||
| + | <code code="30954-2" displayName="STUDIES SUMMARY" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> | ||
| + | <text>Text as described above</text> | ||
| + | </section> | ||
| + | </component> | ||
| − | + | <!-- 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> | </ClinicalDocument> | ||
Revision as of 15:44, 28 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 | |
| Resolved Problems |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.8 | Past Medical History |
| 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 | |
| Results |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.27 | Diagnostic Findings |
| 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>
<!-- Resolved Problems -->
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.8"/>
<id root=" " extension=" "/>
<code code="11348-0" displayName="HISTORY OF PAST ILLNESS" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>Text as described above</text>
<entry>:
<!-- Required Problem Concern Entry element -->
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.2"/>:</entry>
</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 -->
<component>
<section>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.27"/>
<id root=" " extension=" "/>
<code code="30954-2" displayName="STUDIES SUMMARY" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
<text>Text as described above</text>
</section>
</component>
<!-- 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 - use Resolved Problems list instead
| 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.