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Tsoutherland (talk | contribs) (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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''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 |
---|---|---|---|---|
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 |