1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
Development Only
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Antepartum History and Physical Specification 1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1
The Antepartum History and Physical contains a record of the initial History and Physical usually performed during the initial visit.
Format Code
The XDSDocumentEntry format code for this content is urn:ihe:pcc:apr:handp:2008
Parent Template
This document is an instance of the History and Physical template.
LOINC Code
The LOINC code for this document is 34117-2 HISTORY AND PHYSICAL
Standards
CDAR2 | HL7 CDA Release 2.0 |
CCD | ASTM/HL7 Continuity of Care Document |
CDTHP | CDA for Common Document Types History and Physical Notes (DSTU) |
Data Element Index
Data Element | CDA Section | Comments |
---|---|---|
Header | Header | |
Chief Complaint | Chief Complaint | |
Pregnancy History | Pregnancy History | Summary (Gravida Para Abortus) and detailed history of pregnancies |
Medical History | History of Past Illness | Exclude social and family history (included in other sections) |
Medical History - Tobacco, Alcohol, Drugs | Social History | |
Medical History - Relevant Family History | Family History | |
Medications | Medications | |
Allergies | Allergies and Other Adverse Reactions Section | |
Menstrual History/Symptoms Since LMP | Review of Systems | |
Genetic Screening/Teratology Counseling | Family History | |
Infection History | History of Infection | |
Initial Physical Examination | Physical Examination | |
Vital Signs | Vital Signs | subsection of Physical Examination |
Diagnostic Findings | This section is required by CDA4CDT H&P - The requirement of the APR specification is to have the antepartum specific laboratory results in the APR Laboratory document. However, this type of data may also be included here. |
Specification
Data Element Name | Opt | Template ID |
---|---|---|
Spouse | R | 1.3.6.1.4.1.19376.1.5.3.1.2.4.1 |
Natural Father of Fetus | R | 1.3.6.1.4.1.19376.1.5.3.1.2.4.2 |
Enthnicity The enthnicity of the patient should be recorded |
R2 | |
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 |
History of Past Illness This section is the same as it is for History and Physical, however it SHALL contain entries and SHOULD use codes as specified in the Antepartum History and Physical History of Past Illness Value Set. A negative diagnosis SHALL be recorded with the use of the negation indicator attribute. If the data is not present or not available within the system no entry is required. |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.8 |
History of Infection This section SHALL contain coded entries for infection history and SHOULD use the codes as specified in the Antepartum Infection History Value Set. |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1 |
Pregnancy History This section SHALL use the existing Pregnancy History Section and follow all constraints as specified therein. |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4 |
Social History This section is the same as it is for History & Physical, however it SHALL contain coded entries and SHOULD use the codes specified in the Antepartum Social History Value Set. If the data is not present or not available within the system no entries are required. |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.16 |
Coded Family Medical History This section is the same as it is for History & Physical, however it SHALL contain Genetic Screening and Teratology Counseling information as specified in the Antepartum Family History and Genetic Screening Value Set. If the data is not present or not available within the system no entries are required. |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.15 |
Review of Systems This section is the same as it is for History & Physical, however it SHALL include organizers for Menstrual History and MAY include entries for general review of systems data. The Menstrual History entries SHOULD use the codes specified in the Antepartum Menstrual History Value Set. The section code value for the Menstrual History organizer SHALL be '49033-4'. The codeSystem is '2.16.840.1.113883.6.1'. The codeSystemName is 'LOINC'. |
R | 1.3.6.1.4.1.19376.1.5.3.1.3.18 |
Physical Examination This section is the same as it is for History & Physical, and if Vital Signs data are present it SHALL include a Vital Signs subsection. |
R | 1.3.6.1.4.1.19376.1.5.3.1.1.9.15 |
Vital Signs If Vital Signs data are present they SHALL be included as a subsection of Physical Examination. |
C | 1.3.6.1.4.1.19376.1.5.3.1.3.25 |
Conformance
CDA Release 2.0 documents that conform to the requirements of this content module shall indicate their conformance by the inclusion of the appropriate <templateId> elements in the header of the document. This is shown in the sample document below. A CDA Document may conform to more than one template. This content module inherits from the History and Physical content module, and so must conform to the requirements of that template as well, thus all <templateId> elements shown in the example below shall be included.
<ClinicalDocument xmlns='urn:hl7-org:v3'> <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4'/> |
Schematron
<pattern name='Template_1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1'> <rule context='*[cda:templateId/@root="1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1"]'> <!-- Verify that the template id is used on the appropriate type of object --> <assert test='../cda:ClinicalDocument'> Error: The Antepartum History and Physical can only be used on Clinical Documents. </assert> <!-- Verify that the parent templateId is also present. --> <assert test='cda:templateId[@root="1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4"]'> Error: The parent template identifier for Antepartum History and Physical is not present. </assert> <!-- Verify the document type code --> <assert test='cda:code[@code = "34117-2"]'> Error: The document type code of a Antepartum History and Physical must be 34117-2 </assert> <assert test='cda:code[@codeSystem = "2.16.840.1.113883.6.1"]'> Error: The document type code must come from the LOINC code system (2.16.840.1.113883.6.1). </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.4.1"]'> <!-- Verify that all required data elements are present --> Error: The Antepartum History and Physical Document must contain a(n) Spouse Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.2.4.2"]'> <!-- Verify that all required data elements are present --> Error: The Antepartum History and Physical Document must contain a(n) Natural Father of Fetus Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = ""]'> <!-- Alert on any missing required if known elements --> Warning: The Antepartum History and Physical Document should contain a(n) Enthnicity Entry. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1"]'> <!-- Verify that all required data elements are present --> Error: The Antepartum History and Physical Document must contain a(n) Chief Complaint Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.4"]'> <!-- Verify that all required data elements are present --> Error: The Antepartum History and Physical Document must contain a(n) History of Present Illness Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.8"]'> <!-- Verify that all required data elements are present --> Error: The Antepartum History and Physical Document must contain a(n) History of Past Illness Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1"]'> <!-- Verify that all required data elements are present --> Error: The Antepartum History and Physical Document must contain a(n) History of Infection Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4"]'> <!-- Verify that all required data elements are present --> Error: The Antepartum History and Physical Document must contain a(n) Pregnancy History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.16"]'> <!-- Verify that all required data elements are present --> Error: The Antepartum History and Physical Document must contain a(n) Social History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.15"]'> <!-- Verify that all required data elements are present --> Error: The Antepartum History and Physical Document must contain a(n) Coded Family Medical History Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.18"]'> <!-- Verify that all required data elements are present --> Error: The Antepartum History and Physical Document must contain a(n) Review of Systems Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.1.9.15"]'> <!-- Verify that all required data elements are present --> Error: The Antepartum History and Physical Document must contain a(n) Physical Examination Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> <assert test='.//cda:templateId[@root = "1.3.6.1.4.1.19376.1.5.3.1.3.25"]'> <!-- Manually verify condtional elements --> Manual: This Antepartum History and Physical Document does not contain a(n) Vital Signs Section. See http://wiki.ihe.net/index.php?title=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1 </assert> </rule> </pattern>
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