Difference between revisions of "1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1"

Latest revision as of 16:44, 17 September 2008

Development Only

The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

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.

Sample Antepartum History and Physical Document

<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'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1'/>
  <id root=' ' extension=' '/>
  <code code='34117-2' displayName='HISTORY AND PHYSICAL'
    codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
  <title>Antepartum History and Physical</title>
  <effectiveTime value='20240503012005'/>
  <confidentialityCode code='N' displayName='Normal' 
    codeSystem='2.16.840.1.113883.5.25' codeSystemName='Confidentiality' />
  <languageCode code='en-US'/>     
     :
  <component><structuredBody>
    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
        <!-- Required Chief Complaint Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
        <!-- Required History of Present Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.8'/>
        <!-- Required History of Past Illness Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1'/>
        <!-- Required History of Infection Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4'/>
        <!-- Required Pregnancy History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
        <!-- Required Social History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.15'/>
        <!-- Required Coded Family Medical History Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
        <!-- Required Review of Systems Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.9.15'/>
        <!-- Required Physical Examination Section content -->
      </section>
    </component>

    <component>
      <section>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
        <!-- Conditional Vital Signs Section content -->
      </section>
    </component>

       
  </structuredBody></component>
</ClinicalDocument>

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>

@@ Line 1: / Line 1: @@
-{{CDA Document|Antepartum Record History and Physical|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1|Comment|
+{{CDA Document|Antepartum History and Physical|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1|Comment|
-The Antepartum Record History and Physical inherits all constraints from the {{ILink|APR|New_PCC_History_and_Physical|IHE History and Physical}} and also requires the following additional constraints.
+The Antepartum History and Physical contains a record of the initial History and Physical usually performed during the initial visit.
-|Index={{T|Data Element|CDA Section|Comments|Caption=Antepartum Record History and Physical Data Elements|Rows=
+|Index={{T|Data Element|CDA Section|Comments|Caption=Antepartum History and Physical Data Elements|Rows=
-{{R|Header||Need to include Language, Ethnicity, Husband/Domestic Partner, Father of Baby; needs further analysis}}
+{{R|Header||Header}}
 {{R|Chief Complaint|Chief Complaint|}}
 {{R|Pregnancy History|Pregnancy History|Summary (Gravida Para Abortus) and detailed history of pregnancies}}
-{{R|Medical History|Past Medical History|Exclude social and family history (included in other sections)}}
+{{R|Medical History|History of Past Illness|Exclude social and family history (included in other sections)}}
 {{R|Medical History - Tobacco, Alcohol, Drugs|Social History|}}
 {{R|Medical History - Relevant Family History|Family History|}}
@@ Line 15: / Line 15: @@
 {{R|Initial Physical Examination|Physical Examination|}}
 {{R|Vital Signs|Vital Signs|subsection of Physical Examination}}
-{{R|Diagnostic Findings||This section is required by CDA4CDT H&P - The intent in 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.}}
+{{R|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.}}
 }}
-|LOINC=LOINC TBD|LOINCName=TBD
+|LOINC=34117-2|LOINCName=HISTORY AND PHYSICAL
-|Parent=ParentOID|ParentName=History and Physical
+|Parent=1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4|ParentName=History and Physical
-|formatCode=formatCode
+|formatCode=urn:ihe:pcc:apr:handp:2008
 |Standards={{Std|CDAR2}}
 {{Std|CCD}}
@@ Line 28: / Line 28: @@
 |Section|Chief Complaint|R|1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1|
 |Section|History of Present Illness|R|1.3.6.1.4.1.19376.1.5.3.1.3.4|
-|Section|Past Medical History|R|1.3.6.1.4.1.19376.1.5.3.1.3.8|This section is the same as it is for History & Physical, and it SHALL contain entries and SHOULD use the codes specified in the appropriate APR Past Medical History tables.
+|Section|History of Past Illness|R|1.3.6.1.4.1.19376.1.5.3.1.3.8|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.
-There is currently a CP to change this section name from Resolved Problems to Past Medical History.
+|Section|History of Infection|R|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1.1|This section SHALL contain coded entries for infection history and SHOULD use the codes as specified in the {{ILink|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1|1.3.6.1.4.1.19376.1.5.3.1.1.16.5.6|Antepartum Infection History Value Set}}.
-|Section|Pregnancy History|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|This section will consist of two entries, both of which will live under the existing Pregnancy History section.<br/>
+|Section|Pregnancy History|R|1.3.6.1.4.1.19376.1.5.3.1.1.5.3.4|This section SHALL use the existing Pregnancy History Section and follow all constraints as specified therein.
-''Fields that don't exist in the current Pregnancy Observation list:'''
+|Section|Social History|R|1.3.6.1.4.1.19376.1.5.3.1.3.16|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 {{ILink|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1|1.3.6.1.4.1.19376.1.5.3.1.1.16.5.3|Antepartum Social History Value Set}}.  If the data is not present or not available within the system no entries are required.
-Summary - ectopics, multiple births
+|Section|Coded Family Medical History|R|1.3.6.1.4.1.19376.1.5.3.1.3.15|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 {{ILink|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1|1.3.6.1.4.1.19376.1.5.3.1.1.16.5.4|Antepartum Family History and Genetic Screening Value Set}}. If the data is not present or not available within the system no entries are required.
-Details - length of labor, birth weight, sex, type of delivery, anesthestics, place of delivery, preterm labor
+|Section|Review of Systems|R|1.3.6.1.4.1.19376.1.5.3.1.3.18|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 {{ILink|1.3.6.1.4.1.19376.1.5.3.1.1.16.1.1|1.3.6.1.4.1.19376.1.5.3.1.1.16.5.5|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'.
-|Section|Pregnancy Summary History|R|&nbsp;|SHALL use the existing observation Pregnancy Observation and MAY use LOINC or SNOMED CT coded value sets
-|Section|Pregnancy Detail History|O|&nbsp;|Will contain the details of each pregnancy as specified in the APR H&P Pregnancy History Observation Codes table.
-|Section|Social History|R|1.3.6.1.4.1.19376.1.5.3.1.3.16|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 APR H&P Social History Observation Codes table.
-|Section|Coded Family Medical History|R|1.3.6.1.4.1.19376.1.5.3.1.3.15|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 APR H&P Family History and Genetic Screening Observation Codes tables. This section SHOULD also contain any additional relevant family history.
-|Section|Review of Systems|R|1.3.6.1.4.1.19376.1.5.3.1.3.18|This section is the same as it is for History & Physical, however it SHALL include organizers for Menstrual History and MAY include CDA entries for general review of systems data. The 'Menstrual History observations SHOULD use the codes specified in the APR H&P Review of Systems - Menstrual History Observation Codes table. The section code for the Menstrual History organizer SHALL be 49033-4 and the code system name is LOINC.
-|Section|History of Infection|R|1.3.6.1.4.1.19376.1.5.3.1.1.16.2.1|This section SHALL contain coded entries for infection history and SHOULD use the codes as specified in the APR H&P History of Infection Observation Codes table.
 |Section|Physical Examination|R|1.3.6.1.4.1.19376.1.5.3.1.1.9.15|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.
 |Section|Vital Signs|C|1.3.6.1.4.1.19376.1.5.3.1.3.25|If Vital Signs data are present they SHALL be included as a subsection of Physical Examination.
 }}