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 inherits from Medical Summaries (which inherits from CRS and CDA respectively)
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 Past Medical History
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
Results
 R 1.3.6.1.4.1.19376.1.5.3.1.3.27 Diagnostic Findings; use this OR Coded Results
Coded Results
 R 1.3.6.1.4.1.19376.1.5.3.1.3.28 Diagnostic Findings; use this OR Results
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>

      <!-- Resolved Problems -->
      <component>
        <section>
          <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.8"/>
          <id root=" " extension=" "/>
          <code code="11348-0" displayName="HISTORY OF PAST ILLNESS" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
          <text>Text as described above</text>
          <entry>:
            <!-- Required Problem Concern Entry element -->
            <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.5.2"/>:</entry>
        </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 -->
      <component>
        <section>
          <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.27"/>
          <id root=" " extension=" "/>
          <code code="30954-2" displayName="STUDIES SUMMARY" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
          <text>Text as described above</text>
        </section>
      </component>

      <!-- 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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