| 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) |
| Used by / Uses |
| Used by 1 template, Uses 0 templates |
|
|
|
| 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
|
|
CONF |
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 |
|