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==
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{| border=1 cellspacing=0
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|-
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!style='background-color:#cfcfcf;'|TemplateID
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| 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?
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|-
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!style='background-color:#cfcfcf;'|Parent Template
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| colspan=2|
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|-
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!style='background-color:#cfcfcf;'|General Description
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|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.
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|- style='background-color:#cfcfcf;'
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!LOINC Code
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!Opt
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!Description
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|-
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|11348-0
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|align='center'|R
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|Past Medical History
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|}
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==== Sample Past Medical History Section ====
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<pre>
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  <component>
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    <section>
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      <templateId root= 2.16.840.1.113883.10.20.2.9 />
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      <code code='11348-0' codeSystem="2.16.840.1.113883.6.1" displayName='HISTORY OF PAST ILLNESS'/>
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      <title>PAST MEDICAL HISTORY</title>
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      <text>Text as described above</text>
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    </section>
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  </component>
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</pre>
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=== entry ===
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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
Antepartum History and Physical Constraints
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.

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