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
| 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 |
| 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 | |
| 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 |
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 exactly one and SHALL NOT contain more than one Past Medical History section (templateId 2.16.840.1.113883.10.20.2.9), it SHALL contain a narrative block, and it SHOULD contain clinical statements. This section references what has been defined in CDA4CDT History & Physical Note. | |
| 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.