1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4: Difference between revisions

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New page: =Introduction= ''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...
 
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=Introduction=
''This is a draft of a History and Physical Template.  This draft is a work in progress, not the official supplement or profile. ''
''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).
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 ====
{| cellspacing=0 border=1 align='center'
! style='background-color:#cfcfcf'|Data Element
! style='background-color:#cfcfcf'|Opt
!  style='background-color:#cfcfcf'|Section
! style='background-color:#cfcfcf' |Template ID
! style='background-color:#cfcfcf' |Comments
|+ Antepartum History and Physical Constraints
|-
|'''Header'''
||R || ||2.16.840.1.113883.10.20.2
|-
|'''Reason for Visit/Chief Complaint''' <br/>
||R || ||2.16.840.1.113883.10.20.2.9 ||CDA4CDT requires this, but not so sure if it should be required here.
|-
|'''History of Present Illness'''<br/>
||R || ||1.3.6.1.4.1.19376.1.5.3.1.3.4 ||existing IHE Section
|-
|'''Past Medical History'''<br/>
||R || ||2.16.840.1.113883.10.20.2.9 ||new IHE section
|-
|'''Social History'''<br/>
||R || ||1.3.6.1.4.1.19376.1.5.3.1.3.16 ||
|-
|'''Family History'''<br/>
||R || ||2.16.840.1.113883.10.20.1.4 ||
|-
|'''Review of Systems'''<br/>
||R || ||3.6.1.4.1.19376.1.5.3.1.3.18 ||
|-
|'''Physical Examination'''<br/>
||R || ||2.16.840.1.113883.10.20.2.10 ||
|-
|}

Revision as of 12:50, 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

Data Element Opt Section Template ID Comments
Antepartum History and Physical Constraints
Header R 2.16.840.1.113883.10.20.2
Reason for Visit/Chief Complaint
R 2.16.840.1.113883.10.20.2.9 CDA4CDT requires this, but not so sure if it should be required here.
History of Present Illness
 R 1.3.6.1.4.1.19376.1.5.3.1.3.4 existing IHE Section
Past Medical History
 R 2.16.840.1.113883.10.20.2.9 new IHE section
Social History
 R 1.3.6.1.4.1.19376.1.5.3.1.3.16
Family History
 R 2.16.840.1.113883.10.20.1.4
Review of Systems
 R 3.6.1.4.1.19376.1.5.3.1.3.18
Physical Examination
 R 2.16.840.1.113883.10.20.2.10
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