1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4: Difference between revisions
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|Past Medical History<br/> | |Past Medical History<br/> | ||
||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 | ||
|- | |||
|Medications <br/> | |||
||R || || | |||
|- | |||
|Allergies <br/> | |||
||R || || | |||
|- | |- | ||
|[[1.3.6.1.4.1.19376.1.5.3.1.3.16 | Social History]]<br/> | |[[1.3.6.1.4.1.19376.1.5.3.1.3.16 | Social History]]<br/> | ||
| Line 29: | Line 36: | ||
|[[1.3.6.1.4.1.19376.1.5.3.1.3.14 | Family History]]<br/> | |[[1.3.6.1.4.1.19376.1.5.3.1.3.14 | Family History]]<br/> | ||
||R ||1.3.6.1.4.1.19376.1.5.3.1.3.14 || | ||R ||1.3.6.1.4.1.19376.1.5.3.1.3.14 || | ||
|- | |||
|Vital Signs <br/> | |||
||R || || | |||
|- | |- | ||
|[[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/> | ||
| Line 35: | Line 45: | ||
|[[1.3.6.1.4.1.19376.1.5.3.1.3.24 | Physical Examination]]<br/> | |[[1.3.6.1.4.1.19376.1.5.3.1.3.24 | Physical Examination]]<br/> | ||
||R ||1.3.6.1.4.1.19376.1.5.3.1.3.24 || | ||R ||1.3.6.1.4.1.19376.1.5.3.1.3.24 || | ||
|- | |||
|Diagnostic Findings<br/> | |||
||R || || | |||
|- | |||
|Assessment and Plan<br/> | |||
||R || || plan of care i think | |||
|- | |- | ||
|} | |} | ||
Revision as of 18:03, 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 | ||
| Allergies |
R | ||
| 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 | ||
| 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 | ||
| Assessment and Plan |
R | plan of care i think |
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.