1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4

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

IHE PCC History and Physical

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	1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies	R	1.3.6.1.4.1.19376.1.5.3.1.3.13
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	1.3.6.1.4.1.19376.1.5.3.1.3.25
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		Lab results and other findings - need to add IHE section?
Assessment and Plan	R	1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5

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.