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
| 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 |