| Id |
2.16.840.1.113883.10.20.22.2.39 |
Effective Date |
valid from 2016‑10‑09 02:22:53 |
| Status |
 Draft
|
Version Label |
1.1 |
| Name |
MedicalGeneralHistorySection |
Display Name |
Medical (General) History Section |
| Description |
The Medical History section describes all aspects of the medical history of the patient
even if not pertinent to the current procedure, and may include chief complaint, past
medical history, social history, family history, surgical or procedure history, medication
history, and other history information. The history may be limited to information
pertinent to the
current procedure or may be more comprehensive. The history may be reported as a collection
of random clinical statements or it may be reported categorically. Categorical report
formats may be divided into multiple subsections including Past Medical History, Social
History.
|
| Context |
Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.39 |
| Classification |
CDA Section Level Template |
| Open/Closed |
Open (other than defined elements are allowed) |
| Relationship |
Specialization: template 2.16.840.1.113883.10.20.22.2.39 (2013‑01‑31)
|
| Item |
DT |
Card |
Conf |
Description |
Label |
|
|
|
|
|
|
(MedicalGeneralHistorySection) |
 |
cda:templateId
|
|
II |
1 … 1 |
M |
SHALL contain exactly one [1..1] templateId (CONF:8160) such that it |
conf‑8160 |
 |
|
@root
|
|
uid |
1 … 1 |
F |
2.16.840.1.113883.10.20.22.2.39 |
conf‑10403 |
|
cda:code
|
|
CE |
1 … 1 |
M |
SHALL contain exactly one [1..1] code (CONF:15379). |
conf‑15379 |
|
|
@code
|
|
|
1 … 1 |
F |
11329-0 |
|
|
@codeSystem
|
|
|
1 … 1 |
F |
2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes) |
|
cda:title
|
|
ST |
1 … 1 |
R |
SHALL contain exactly one [1..1] title (CONF:8162). |
conf‑8162 |
|
cda:text
|
|
SD.TEXT |
1 … 1 |
M |
SHALL contain exactly one [1..1] text (CONF:8163). |
conf‑8163 |
|