Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.9"

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{{CDA Document|Preprocedure History and Physical|1.3.6.1.4.1.19376.1.5.3.1.1.9|Draft|
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{{CDA Document|Preprocedure History and Physical|1.3.6.1.4.1.19376.1.5.3.1.1.9|Comment|
 
A Pre-procedure History and Physical is a type of medical document, and incorporates the constraints defined for {{ITmpRef|1.3.6.1.4.1.19376.1.5.3.1.1.1|Medical Documents|1.3.6.1.4.1.19376.1.5.3.1.1.9}}.
 
A Pre-procedure History and Physical is a type of medical document, and incorporates the constraints defined for {{ITmpRef|1.3.6.1.4.1.19376.1.5.3.1.1.1|Medical Documents|1.3.6.1.4.1.19376.1.5.3.1.1.9}}.
  
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CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document.  This is shown below.  Note that a Preprocedure History and Physical is a Medical Document, and so includes that <templateId> element as well.
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This use case is described fully in in the PPHP Profile described in PCC TF-1.  Briefly, this use case involves a sequence of events leading up to the patient’s admission to the operating room in a surgical center. Included in these events is the creation and communication of the pre-procedure history and physical document required by quality review organizations prior to most surgeries. Using this use case, the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below under the column “Use Case Documentation Section??.  
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<pre>
 
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<ClinicalDocument xmlns='urn:hl7-org:v3'>
 
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  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
 
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  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.9"/>
 
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  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/>
 
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    :
 
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</pre>
 
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A CDA Document may conform to more than one template, and can therefore have more that one <templateId> element.  The <templateId> elements shown above must be present in the document.
 
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This use case is described fully in PCC TF-1: 7.4.  Briefly, this use case involves a sequence of events leading up to the patient’s admission to the operating room in a surgical center. Included in these events is the creation and communication of the pre-procedure history and physical document required by quality review organizations prior to most surgeries. Using this use case, the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below under the column “Use Case Documentation Section”.  
 
  
 
Using this information from the use case, the following mappings were made to existing standards and implementation guides. As illustrated, there is quite a bit of overlap between sections in this integration profile and in sections specified in the HL7 Care Record Summary CDA implementation guide.
 
Using this information from the use case, the following mappings were made to existing standards and implementation guides. As illustrated, there is quite a bit of overlap between sections in this integration profile and in sections specified in the HL7 Care Record Summary CDA implementation guide.
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|Parent=1.3.6.1.4.1.19376.1.5.3.1.1.1|ParentName=Medical Document
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Standards={{Std|CDAR2|HL7 CDA Release 2.0}}
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|Standards={{Std|CDAR2}}
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{{Std|CAREPROV|HL7 Care Provision DSTU}}
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{{Std|CRS}}
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{{Std|CRS|HL7 Care Record Summary}}
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{{Std|CCD}}
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{{Std|CCD|ASTM/HL7 Continuity of Care Document}}
 
 
|Index=
 
|Index=
 
{{T|Data Element Requirements|Sections in HL7 CDA-R2/|LOINC Descriptions|
 
{{T|Data Element Requirements|Sections in HL7 CDA-R2/|LOINC Descriptions|
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{{R|Patient Education/Consents|&nbsp;|EDUCATION NOTE}}
 
{{R|Patient Education/Consents|&nbsp;|EDUCATION NOTE}}
 
}}
 
}}
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|Data={{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Proposed Procedure: (coded procedure) includes:|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.1|Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.}}
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|Section|Proposed Procedure: (coded procedure) includes:|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.1|Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Reason for Procedure: (coded diagnosis)|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.4|Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.}}
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|Section|-Reason for Procedure: (coded diagnosis)|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.4|Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Proposed Anesthesia|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.3|Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.}}
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|Section|-Proposed Anesthesia|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.3|Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Expected Blood Loss|R2|1.3.6.1.4.1.19376.1.5.3.1.1.9.2|Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.<br/>Needs narrative LOINC code}}
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|Section|-Expected Blood Loss|R2|1.3.6.1.4.1.19376.1.5.3.1.1.9.2|Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.<br/>Needs narrative LOINC code
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Procedure Care Plan|R2|1.3.6.1.4.1.19376.1.5.3.1.1.9.40|Care Plan generated by the surgeon or surgical coordinator prior to the H&P}}
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|Section|-Procedure Care Plan|R2|1.3.6.1.4.1.19376.1.5.3.1.1.9.40|Care Plan generated by the surgeon or surgical coordinator prior to the H&P
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|HPI—(free text leading up to procedure)|R|1.3.6.1.4.1.19376.1.5.3.1.3.4|}}
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|Section|HPI—(free text leading up to procedure)|R|1.3.6.1.4.1.19376.1.5.3.1.3.4|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Current Problem List|R2|1.3.6.1.4.1.19376.1.5.3.1.3.6|Problem List (if known) is represented as current at beginning of H&P encounter.}}
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|Section|Current Problem List|R2|1.3.6.1.4.1.19376.1.5.3.1.3.6|Problem List (if known) is represented as current at beginning of H&P encounter.
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Past Medical History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.8|}}
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|Section|Past Medical History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.8|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Past Surgical-Anesthesia History|R|1.3.6.1.4.1.19376.1.5.3.1.3.11|}}
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|Section|Past Surgical-Anesthesia History|R|1.3.6.1.4.1.19376.1.5.3.1.3.11|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Medication List|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|}}
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|Section|Medication List|R|1.3.6.1.4.1.19376.1.5.3.1.3.19|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Allergy List|R|1.3.6.1.4.1.19376.1.5.3.1.3.13|}}
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|Section|Allergy List|R|1.3.6.1.4.1.19376.1.5.3.1.3.13|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Immunizations|R2|1.3.6.1.4.1.19376.1.5.3.1.3.23|}}
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|Section|Immunizations|R2|1.3.6.1.4.1.19376.1.5.3.1.3.23|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|History of Tobacco Use|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.8|}}
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|Section|History of Tobacco Use|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.8|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Current Alcohol/Substance  Abuse|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.10|}}
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|Section|Current Alcohol/Substance  Abuse|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.10|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Transfusion History|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.12|}}
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|Section|Transfusion History|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.12|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Pre-procedure Family History|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.5|}}
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|Section|Pre-procedure Family History|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.5|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Social History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.16|}}
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|Section|Social History|R2|1.3.6.1.4.1.19376.1.5.3.1.3.16|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Advance Directives|R2|1.3.6.1.4.1.19376.1.5.3.1.3.34|}}
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|Section|Advance Directives|R2|1.3.6.1.4.1.19376.1.5.3.1.3.34|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Functional Capacity|R|1.3.6.1.4.1.19376.1.5.3.1.3.17|}}
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|Section|Functional Capacity|R|1.3.6.1.4.1.19376.1.5.3.1.3.17|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Review of Systems (specifically includes):|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.13|}}
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|Section|Review of Systems (specifically includes):|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.13|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|  -General Review|R|1.3.6.1.4.1.19376.1.5.3.1.3.18|}}
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|Section|  -General Review|R|1.3.6.1.4.1.19376.1.5.3.1.3.18|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Implanted Medical Devices|R2|1.3.6.1.4.1.19376.1.5.3.1.1.9.46|}}
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|Section|-Implanted Medical Devices|R2|1.3.6.1.4.1.19376.1.5.3.1.1.9.46|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Pregnancy Status (if female)|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.47|}}
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|Section|-Pregnancy Status (if female)|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.47|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|  -Anesthesia Review of Systems|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.14|}}
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|Section|  -Anesthesia Review of Systems|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.14|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Physical Exam (specifically includes):|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|}}
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|Section|Physical Exam (specifically includes):|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Vitals|R|1.3.6.1.4.1.19376.1.5.3.1.9.49|}}
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|Section|-Vitals|R|1.3.6.1.4.1.19376.1.5.3.1.9.49|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-General Appearance|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.16|}}
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|Section|-General Appearance|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.16|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Visible Implanted Medical Devices|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.48|}}
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|Section|-Visible Implanted Medical Devices|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.48|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Integumentary System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.17|}}
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|Section|-Integumentary System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.17|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Head|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.18|}}
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|Section|-Head|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.18|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Eyes|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.19|}}
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|Section|-Eyes|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.19|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Ears, Nose, Mouth and Throat (may include):|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1|}}
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|Section|-Ears, Nose, Mouth and Throat (may include):|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|--Ears|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.21|}}
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|Section|--Ears|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.21|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|--Nose|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.22|}}
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|Section|--Nose|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.22|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|--Mouth, Throat, and Teeth|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.23|}}
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|Section|--Mouth, Throat, and Teeth|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.23|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Neck|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.24|}}
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|Section|-Neck|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.24|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Endocrine System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.25|}}
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|Section|-Endocrine System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.25|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Thorax and Lungs (may include):|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1|}}
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|Section|-Thorax and Lungs (may include):|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|--Chest Wall|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.27|}}
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|Section|--Chest Wall|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.27|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|--Breasts|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.28|}}
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|Section|--Breasts|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.28|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|--Heart|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.29|}}
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|Section|--Heart|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.29|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|--Respiratory System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.30|}}
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|Section|--Respiratory System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.30|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Abdomen|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.31|}}
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|Section|-Abdomen|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.31|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Lymphatic System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.32|}}
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|Section|-Lymphatic System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.32|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Vessels|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.33|}}
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|Section|-Vessels|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.33|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Musculoskeletal System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.34|}}
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|Section|-Musculoskeletal System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.34|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Neurologic System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.35|}}
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|Section|-Neurologic System|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.35|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Genitalia|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.36|}}
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|Section|-Genitalia|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.36|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|-Rectum|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.37|}}
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|Section|-Rectum|O|1.3.6.1.4.1.19376.1.5.3.1.1.9.37|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Studies and Reports|R2|1.3.6.1.4.1.19376.1.5.3.1.3.28|}}
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|Section|Studies and Reports|R2|1.3.6.1.4.1.19376.1.5.3.1.3.28|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Health Maintenance Care Plan Status Report|R2|1.3.6.1.4.1.19376.1.5.3.1.1.9.41|Actions completed to date}}
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|Section|Health Maintenance Care Plan Status Report|R2|1.3.6.1.4.1.19376.1.5.3.1.1.9.41|Actions completed to date
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Procedure Care Plan Status Report|R2|1.3.6.1.4.1.19376.1.5.3.1.1.9.45|Actions completed to date}}
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|Section|Procedure Care Plan Status Report|R2|1.3.6.1.4.1.19376.1.5.3.1.1.9.45|Actions completed to date
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Pre-procedure Impressions (specifically includes):|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.42|}}
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|Section|Pre-procedure Impressions (specifically includes):|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.42|
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|  - Problems|R|1.3.6.1.4.1.19376.1.5.3.1.3.6|Updated at completion of encounter}}
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|Section|  - Problems|R|1.3.6.1.4.1.19376.1.5.3.1.3.6|Updated at completion of encounter
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|  -Pre-Procedure Risk Assessment|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.44|Content same as corresponding Op Note section except that this section describes what is at risk of happening instead of what happened.}}
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|Section|  -Pre-Procedure Risk Assessment|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.44|Content same as corresponding Op Note section except that this section describes what is at risk of happening instead of what happened.
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{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Procedure Care Plan|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.40|Updated with additional or modified actions to be executed in future}}
+
|Section|Procedure Care Plan|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.40|Updated with additional or modified actions to be executed in future
−
{{CDA Document Content|1.3.6.1.4.1.19376.1.5.3.1.1.9|Patient Education/Consents|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.38|Performed during H&P encounter}}
+
|Section|Patient Education/Consents|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.38|Performed during H&P encounter}}
−
 
 
−
}}
 

Revision as of 14:38, 5 June 2007

Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Comment.gif Preprocedure History and Physical Specification 1.3.6.1.4.1.19376.1.5.3.1.1.9

A Pre-procedure History and Physical is a type of medical document, and incorporates the constraints defined for Medical Documents(1.3.6.1.4.1.19376.1.5.3.1.1.1) .

This use case is described fully in in the PPHP Profile described in PCC TF-1. Briefly, this use case involves a sequence of events leading up to the patient’s admission to the operating room in a surgical center. Included in these events is the creation and communication of the pre-procedure history and physical document required by quality review organizations prior to most surgeries. Using this use case, the contents of documents used in collaborative transfers of care were discussed with physicians and nurses in detail to identify major sections. The sections identified by physicians during the use case exercise as important are listed in the table below under the column “Use Case Documentation Section??.

Using this information from the use case, the following mappings were made to existing standards and implementation guides. As illustrated, there is quite a bit of overlap between sections in this integration profile and in sections specified in the HL7 Care Record Summary CDA implementation guide.


Parent Template

This document is an instance of the Medical Document template.

Standards
CDAR2 HL7 CDA Release 2.0
CRS HL7 Care Record Summary
CCD ASTM/HL7 Continuity of Care Document
Data Element Index
Data Element Requirements Sections in HL7 CDA-R2/ LOINC Descriptions
Proposed Procedure: (coded procedure)   PROCEDURE
Expected Blood Loss   OPERATIVE NOTE ESTIMATED BLOOD LOSS
Proposed Anesthesia   OPERATIVE NOTE ANESTHESIA
Reason for Procedure: (coded diagnosis)   OPERATIVE NOTE INDICATIONS
HPI—(free text leading up to procedure) History of Present Illness HISTORY OF PRESENT ILLNESS
Current Problem List Conditions PROBLEM LIST
Past Medical History Conditions HISTORY OF PAST ILLNESS
Past Surgical-Anesthesia History Past Surgical History HISTORY OF SURGICAL PROCEDURES
Medication List Medications HISTORY OF MEDICATION USE
Allergy List Allergies and Adverse Reactions HISTORY OF ALLERGIES
Immunizations Immunizations HISTORY OF IMMUNIZATIONS
History of Tobacco Use   HISTORY OF TOBACCO USE
Current Alcohol/Substance Abuse   HISTORY OF PRESENT ALCOHOL AND/OR SUBSTANCE ABUSE
Transfusion History   TBD
Family History (specifically includes): Family History HISTORY OF FAMILY MEMBER DISEASES
Social History   SOCIAL HISTORY
Advance Directives Advance Directives ADVANCE DIRECTIVES
Functional Capacity Functional Status HISTORY OF FUNCTIONAL STATUS
Review of Systems (specifically includes): Review of Systems REVIEW OF SYSTEMS
Physical Exam (specifically includes): Physical Examination PHYSICAL EXAM.TOTAL
Studies and Reports Studies and Reports STUDIES SUMMARY
Health Maintenance Status   TREATMENT PLAN
Pre-procedure Care Plan Status Report   TREATMENT PLAN
Pre-procedure Impressions (specifically includes):   DIAGNOSIS
-Updated Problem List Conditions PROBLEM LIST
-Pre-Procedure Risk Assessment   OPERATIVE NOTE COMPLICATIONS
Pre-procedure Care Plan Plan of Care TREATMENT PLAN
Patient Education/Consents   EDUCATION NOTE
Specification
Data Element Name Opt Template ID
Proposed Procedure: (coded procedure) includes:
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.1
-Reason for Procedure: (coded diagnosis)
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.4
-Proposed Anesthesia
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened. 		R 1.3.6.1.4.1.19376.1.5.3.1.1.9.3
-Expected Blood Loss
Content same as corresponding Op Note section except that this section describes what is planned to happen instead of what happened.
Needs narrative LOINC code 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.2
-Procedure Care Plan
Care Plan generated by the surgeon or surgical coordinator prior to the H&P 		R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.40
HPI—(free text leading up to procedure) R 1.3.6.1.4.1.19376.1.5.3.1.3.4
Current Problem List
Problem List (if known) is represented as current at beginning of H&P encounter. 		R2 1.3.6.1.4.1.19376.1.5.3.1.3.6
Past Medical History R2 1.3.6.1.4.1.19376.1.5.3.1.3.8
Past Surgical-Anesthesia History R 1.3.6.1.4.1.19376.1.5.3.1.3.11
Medication List R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergy List R 1.3.6.1.4.1.19376.1.5.3.1.3.13
Immunizations R2 1.3.6.1.4.1.19376.1.5.3.1.3.23
History of Tobacco Use R 1.3.6.1.4.1.19376.1.5.3.1.1.9.8
Current Alcohol/Substance Abuse R 1.3.6.1.4.1.19376.1.5.3.1.1.9.10
Transfusion History R 1.3.6.1.4.1.19376.1.5.3.1.1.9.12
Pre-procedure Family History R 1.3.6.1.4.1.19376.1.5.3.1.1.9.5
Social History R2 1.3.6.1.4.1.19376.1.5.3.1.3.16
Advance Directives R2 1.3.6.1.4.1.19376.1.5.3.1.3.34
Functional Capacity R 1.3.6.1.4.1.19376.1.5.3.1.3.17
Review of Systems (specifically includes): R 1.3.6.1.4.1.19376.1.5.3.1.1.9.13
-General Review R 1.3.6.1.4.1.19376.1.5.3.1.3.18
-Implanted Medical Devices R2 1.3.6.1.4.1.19376.1.5.3.1.1.9.46
-Pregnancy Status (if female) R 1.3.6.1.4.1.19376.1.5.3.1.1.9.47
-Anesthesia Review of Systems R 1.3.6.1.4.1.19376.1.5.3.1.1.9.14
Physical Exam (specifically includes): R 1.3.6.1.4.1.19376.1.5.3.1.1.9.15
-Vitals R 1.3.6.1.4.1.19376.1.5.3.1.9.49
-General Appearance O 1.3.6.1.4.1.19376.1.5.3.1.1.9.16
-Visible Implanted Medical Devices O 1.3.6.1.4.1.19376.1.5.3.1.1.9.48
-Integumentary System O 1.3.6.1.4.1.19376.1.5.3.1.1.9.17
-Head O 1.3.6.1.4.1.19376.1.5.3.1.1.9.18
-Eyes O 1.3.6.1.4.1.19376.1.5.3.1.1.9.19
-Ears, Nose, Mouth and Throat (may include): O 1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1
--Ears O 1.3.6.1.4.1.19376.1.5.3.1.1.9.21
--Nose O 1.3.6.1.4.1.19376.1.5.3.1.1.9.22
--Mouth, Throat, and Teeth O 1.3.6.1.4.1.19376.1.5.3.1.1.9.23
-Neck O 1.3.6.1.4.1.19376.1.5.3.1.1.9.24
-Endocrine System O 1.3.6.1.4.1.19376.1.5.3.1.1.9.25
-Thorax and Lungs (may include): O 1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1
--Chest Wall O 1.3.6.1.4.1.19376.1.5.3.1.1.9.27


Conformance

CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below. A CDA Document may conform to more than one template. This content module inherits from the Medical Document content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.

Sample Preprocedure History and Physical Document 
<ClinicalDocument xmlns='urn:hl7-org:v3'>
  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.1'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9'/>
  <id root=' ' extension=' '/>
  <code code=' ' displayName=' '
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Preprocedure History and Physical</title>
  <effectiveTime value='20241017012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.1'/>
        <!-- Required Proposed Procedure: (coded procedure) includes: Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.4'/>
        <!-- Required -Reason for Procedure: (coded diagnosis) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.3'/>
        <!-- Required -Proposed Anesthesia Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.2'/>
        <!-- Required if known -Expected Blood Loss Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.40'/>
        <!-- Required if known -Procedure Care Plan Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required HPI—(free text leading up to procedure) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.6'/>
        <!-- Required if known Current Problem List Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required if known Past Medical History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.11'/>
        <!-- Required Past Surgical-Anesthesia History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
        <!-- Required Medication List Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
        <!-- Required Allergy List Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.23'/>
        <!-- Required if known Immunizations Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.8'/>
        <!-- Required History of Tobacco Use Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.10'/>
        <!-- Required Current Alcohol/Substance   Abuse Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.12'/>
        <!-- Required Transfusion History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.5'/>
        <!-- Required Pre-procedure Family History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
        <!-- Required if known Social History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.34'/>
        <!-- Required if known Advance Directives Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.17'/>
        <!-- Required Functional Capacity Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.13'/>
        <!-- Required Review of Systems (specifically includes): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Required   -General Review Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.46'/>
        <!-- Required if known -Implanted Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.47'/>
        <!-- Required -Pregnancy Status (if female) Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.14'/>
        <!-- Required   -Anesthesia Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
        <!-- Required Physical Exam (specifically includes): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.9.49'/>
        <!-- Required -Vitals Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.16'/>
        <!-- Optional -General Appearance Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.48'/>
        <!-- Optional -Visible Implanted Medical Devices Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.17'/>
        <!-- Optional -Integumentary System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.18'/>
        <!-- Optional -Head Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.19'/>
        <!-- Optional -Eyes Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1'/>
        <!-- Optional -Ears, Nose, Mouth and Throat (may include): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.21'/>
        <!-- Optional --Ears Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.22'/>
        <!-- Optional --Nose Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.23'/>
        <!-- Optional --Mouth, Throat, and Teeth Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.24'/>
        <!-- Optional -Neck Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.25'/>
        <!-- Optional -Endocrine System Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1'/>
        <!-- Optional -Thorax and Lungs (may include): Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.27'/>
        <!-- Optional --Chest Wall Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.9'>
 <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.9"]'>
   <!-- Verify that the template id is used on the appropriate type of object -->
   <assert test='../cda:ClinicalDocument'>
     Error: The Preprocedure History and Physical can only be used on Clinical Documents.
   </assert> 
   <!-- Verify that the parent templateId is also present. -->
   <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.1"]'>
     Error: The parent template identifier for Preprocedure History and Physical is not present.
   </assert> 
   <!-- Verify the document type code -->
   <assert test='cda:code[@code = "{{{LOINC}}}"]'>
     Error: The document type code of a Preprocedure History and Physical must be {{{LOINC}}}
   </assert>
   <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'>
     Error: The document type code must come from the LOINC code 
     system (2.16.840.1.113883.6.1).
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.1"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Proposed Procedure: (coded procedure) includes: Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Reason for Procedure: (coded diagnosis) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.3"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Proposed Anesthesia Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.2"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Expected Blood Loss Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.40"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Procedure Care Plan Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) HPI—(free text leading up to procedure) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.6"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Current Problem List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9 
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Past Medical History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.11"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Past Surgical-Anesthesia History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.19"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Medication List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Allergy List Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.23"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Immunizations Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.8"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) History of Tobacco Use Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.10"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Current Alcohol/Substance   Abuse Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.12"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Transfusion History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.5"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Pre-procedure Family History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Social History Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.34"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) Advance Directives Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.17"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Functional Capacity Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.13"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Review of Systems (specifically includes): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n)   -General Review Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.46"]'> 
     <!-- Alert on any missing required if known elements -->
     Warning: The  Preprocedure History and Physical Document should contain a(n) -Implanted Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.47"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Pregnancy Status (if female) Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.14"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n)   -Anesthesia Review of Systems Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) Physical Exam (specifically includes): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.9.49"]'> 
     <!-- Verify that all required data elements are present -->
     Error: The Preprocedure History and Physical Document must contain a(n) -Vitals Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.16"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -General Appearance Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.48"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Visible Implanted Medical Devices Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.17"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Integumentary System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.18"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Head Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.19"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Eyes Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.20.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Ears, Nose, Mouth and Throat (may include): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.21"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Ears Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.22"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Nose Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.23"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Mouth, Throat, and Teeth Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.24"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Neck Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.25"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Endocrine System Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.26.1"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) -Thorax and Lungs (may include): Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
   <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.27"]'> 
     <!-- Note any missing optional elements -->
     Note: This Preprocedure History and Physical Document does not contain a(n) --Chest Wall Section.
     See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.9
   </assert> 
 </rule>
</pattern>
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