1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4
Revision as of 07:52, 25 April 2008 by Tsoutherland (talk | contribs) (→Sample Past Medical History Section)
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 |
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' displayName='HISTORY OF PAST ILLNESS' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/> <title>PAST MEDICAL HISTORY</title> <text>Text as described above</text> </section> </component>
entry
Description of the entry element.