1.3.6.1.4.1.19376.1.5.3.1.1.16.1.4

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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
IHE PCC History and Physical
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
Resolved Problems
 R 1.3.6.1.4.1.19376.1.5.3.1.3.8
Medications
R 1.3.6.1.4.1.19376.1.5.3.1.3.19
Allergies and Other Adverse Reactions Section
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
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
Vital Signs
 R 1.3.6.1.4.1.19376.1.5.3.1.3.25
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

Sample IHE History and Physical

<ClinicalDocument>
  <component>
    <structuredBody>
	
      <!-- Chief Complaint -->
	<component>
	  <section>
	    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'/>
	    <id root=' ' extension=' '/>
	    <code code='10154-3' displayName='CHIEF COMPLAINT' 
	      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
	    <text>
	      Text as described above
	    </text>
	  </section>
	</component>

      <!-- History of Present Illness -->
	<component>
	  <section>
	    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.4'/>
	    <id root=' ' extension=' '/>
	    <code code='10164-2' displayName='HISTORY OF PRESENT ILLNESS' 
	      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
	    <text>
	      Text as described above
	    </text>  
	  </section>
	</component>

	<!-- Past Medical History -->
	<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>

	<!-- Medications -->
	<component>
	  <section>
	    <templateId root='2.16.840.1.113883.10.20.1.8'/>
	    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.19'/>
	    <id root=' ' extension=' '/>
	    <code code='10160-0' displayName='HISTORY OF MEDICATION USE' 
	      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
	    <text>
	      Text as described above
	    </text>   
	    <entry>
	         :
	      <!-- Required Medications element -->
	      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.7'/>
	         :
	    </entry>
          </section>
	</component>

	<!-- Allergies-->
	<component>
	  <section>
	    <templateId root='2.16.840.1.113883.10.20.1.2'/>
	    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.13'/>
	    <id root=' ' extension=' '/>
	    <code code='48765-2' displayName='Allergies, adverse reactions, alerts'
	      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
	    <text>
	      Text as described above
	    </text>   
	    <entry>
	         :
	      <!-- Required Allergies and Intolerances Concern element -->
	        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.5.3'/>
	         :
	    </entry>  
	  </section>
	</component>

	<!-- Social History -->
	<component>
	  <section>
	    <templateId root='2.16.840.1.113883.10.20.1.15'/>
	    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.16'/>
	    <id root=' ' extension=' '/>
	    <code code='29762-2' displayName='SOCIAL HISTORY'
	      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
	    <text>
	      Text as described above
	    </text>       
	  </section>
	</component>

	<!-- Family History -->
	<component>
	  <section>
	    <templateId root='2.16.840.1.113883.10.20.1.4'/>
	    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.14'/>
	    <id root=' ' extension=' '/>
	    <code code='10157-6' displayName='HISTORY OF FAMILY MEMBER DISEASES'
	      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
	    <text>
	      Text as described above
	    </text>         
	  </section>
	</component>

	<!-- Review of Systems -->
	<component>
	  <section>
	    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.18'/>
	    <id root=' ' extension=' '/>
	    <code code='10187-3' displayName='REVIEW OF SYSTEMS'
	      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
	    <text>
	      Text as described above
	    </text>         
	  </section>
	</component>

	<!-- Physical Examination -->
	<component>
	  <section>
	    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.24'/>
	    <id root=' ' extension=' '/>
	    <code code='29545-1' displayName='PHYSICAL EXAMINATION'
	      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
	    <text>
	      Text as described above
	    </text>         
	  </section>
	</component>

        <!-- Vital Signs -->
	<component>
	  <section>
	    <templateId root='2.16.840.1.113883.10.20.1.16'/>
	    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.3.25'/>
	    <id root=' ' extension=' '/>
	    <code code='8716-3' displayName='VITAL SIGNS'
	      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
	    <text>
	      Text as described above
	    </text>         
	  </section>
	</component>

	<!-- Diagnostic Findings -->

	<!-- Assessment and Plan -->
	<component>
	  <section>
	    <templateId root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.5'/>
	    <id root=' ' extension=' '/>
	    <code code='X-AANDP' displayName='ASSESSMENT AND PLAN'
	      codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC'/>
	    <text>
	      Text as described above
	    </text>         
	  </section>
	</component>
      </structuredBody>
    </component>
</ClinicalDocument>





Past Medical History Section - use Resolved Problems list instead

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.

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