Template  BC CDA E2E Medical History Section without Entries

The Medical History Section provides details on the past conditions or diagnosis that the patient may have had which would have an effect on their care. Whilst this is very similar to the concept of “Problems & Conditions”, there are some differences in clinical practice that should be recognized.  It is indeed possible to enter the past Medical History as a series of problems that are now inactive; however, regardless of the EMR design, the time required to log the history as distinct inactive problems can be prohibitive and it is common clinical practice to actually capture this information as a single textual narrative. The requirement for coding this history is low as, by definition, these are not active problems. Classic medical school teaching includes a section on Past Medical History and it exists as a distinct section in current specialty consults.

Consequently, whist the Problems & Conditions structure and section could be used to communicate Medical History; the E2E-DTC Specification supports this distinct CDA section for Medical History that may be communicated as human readable narrative text only using Medical History (without entries); or may be coded with the Medical History (without entries) which uses the same Section-Entry Template as provided for the Problems & Conditions Section. Clinical practice and EMR capabilities will dictate if medical history is captured in the same section as Problems & Conditions or as a separate section.