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Template History and Physical 2013‑01‑31

Id2.16.840.1.113883.10.20.22.1.3Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameHistoryandPhysicalDisplay NameHistory and Physical
Description
A History and Physical (H&P) Note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status. The first portion of the report is a current collection of organized information unique to an individual, typically supplied by the patient or their caregiver, about the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members. The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures. The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues. A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an H&P Note.
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 21 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.7Transactionfinal History and Physical (H and P) (Release 1.1)2013‑01‑31
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1Containmentdraft Chief Complaint Section (1.1)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.4Containmentdraft History of Present Illness Section (1.1)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.18Containmentdraft Review of Systems Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.2.5Containmentdraft General Status Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.2.10Containmentdraft Physical Exam Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.1Containmentdraft Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2Containmentdraft Immunizations Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.3Containmentdraft Results Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.4Containmentdraft Vital Signs Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.5Containmentdraft Problem Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6Containmentdraft Allergies Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7Containmentdraft Procedures Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.8Containmentdraft Assessment Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.9Containmentdraft Assessment and Plan Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Care Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.12Containmentdraft Reason for Visit Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.13Containmentdraft Chief Complaint and Reason for Visit Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.15Containmentdraft Family History Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.17Containmentdraft Social History Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.20Containmentdraft History of Past Illness Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.45Containmentdraft Instructions Section (1.1)2013‑01‑31
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
Histdotsical
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:8283) such that itconf‑8283
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.3confdots0046
cda:code
1 … 1RSHALL contain exactly one [1..1] code (CONF:17185).confdots7185
cda:participant
0 … *MAY contain zero or more [0..*] participant (CONF:8286).

A participant element, if present, SHALL contain an associatedEntity element which SHALL contain either an associatedPerson or scopingOrganization element.

A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded.

c. When participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30
conf‑8286
cda:associatedEntity
1 … 1Mconf‑8286
Choice1 … 1
A participant element, if present, SHALL contain an associatedEntity element which SHALL contain either an associatedPerson or scopingOrganization element.
Elements to choose from:
  • cda:associatedPerson
  • cda:scopingOrganization
cda:associatedPerson
conf‑8286
cda:scopingOrganization
conf‑8286
cda:inFulfillmentOf
0 … *MAY contain zero or more [0..*] inFulfillmentOf (CONF:8336).

An inFulfillmentOf element records the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and this H&P Note may be in partial fulfillment of that referral.
conf‑8336
cda:componentOf
1 … 1MSHALL contain exactly one [1..1] componentOf (CONF:8338).conf‑8338
cda:encompassingEncounter
1 … 1MThis componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:8339).conf‑8339
cda:id
II1 … *RThis encompassingEncounter SHALL contain exactly one [1..1] id (CONF:8340).conf‑8340
cda:effectiveTime
1 … 1MThis encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:8341).

The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
conf‑8341
 Schematron assertrolered error 
 testnot(.//@value[not(parent::cda:width)][string-length()<8]) 
 MessageThe content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) 
cda:responsibleParty
0 … 1This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:8345).

The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care.

The responsibleParty element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both.
conf‑8345
cda:assignedEntity
1 … 1Mconf‑8345
Choice1 … 2
The responsibleParty element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both.
Elements to choose from:
  • cda:associatedPerson
  • cda:representedOrganization
cda:associatedPerson
conf‑8345
cda:representedOrganization
conf‑8345
cda:encounterParticipant
0 … *This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:8342).

An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both.

The encounterParticipant element, if present, records only participants in the encounter, not necessarily in the entire episode of care.
conf‑8342
cda:assignedEntity
1 … 1Mconf‑8342
Choice1 … 2
The responsibleParty element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both.
Elements to choose from:
  • cda:associatedPerson
  • cda:representedOrganization
cda:associatedPerson
conf‑8342
cda:representedOrganization
conf‑8342
cda:location
0 … 1This encompassingEncounter MAY contain zero or one [0..1] location (CONF:8344).conf‑8344
cda:component
1 … 1MSHALL contain exactly one [1..1] component (CONF:8349).

A History and Physical document can have either a structuredBody or a nonXMLBody.

A History and Physical document can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.3), coded entries are optional.

If structuredBody, the component/structuredBody SHALL conform to the section constraints below

SHALL include a Chief Complaint and Reason for Visit Section, Chief Complaint Section, or a Reason for Visit Section

SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.

SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present

SHALL NOT contain a Chief Complaint and Reason for Visit Section when either a Chief Complaint Section or a Reason for Visit Section is present
conf‑8349
Choice1 … 1
A History and Physical document can have either a structuredBody or a nonXMLBody.
Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
cda:nonXMLBody
conf‑8349
cda:structuredBody
conf‑8349
 Schematron assertrolered error 
 test.//cda:section/cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1' or .//cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12' or .//cda:section/cda:templateId/@root='2.16.840.1.113883.10.20.22.2.13' 
 MessageSHALL include a Chief Complaint and Reason for Visit Section, Chief Complaint Section, or a Reason for Visit Section 
 Schematron assertrolered error 
 testnot(.//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'] and (.//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] or .//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])) 
 MessageSHALL NOT contain a Chief Complaint and Reason for Visit Section when either a Chief Complaint Section or a Reason for Visit Section is present 
 Schematron assertrolered error 
 test//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'] or (//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] and //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10']) 
 MessageSHALL include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan Section (2.16.840.1.113883.10.20.22.2.10). 
 Schematron assertrolered error 
 testnot(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9']) or ( not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8']) and not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10']) ) 
 MessageSHALL NOT include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9) when an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Care Section (2.16.840.1.113883.10.20.22.2.10) are present 
cda:component
1 … 1RContains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (2013‑01‑31)conf‑9602
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2013‑01‑31)conf‑9605
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31)conf‑9607
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2013‑01‑31)conf‑9611
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2013‑01‑31)conf‑9613
cda:component
1 … 1RContains 2.16.840.1.113883.10.20.22.2.15 Family History Section (2013‑01‑31)conf‑9615
cda:component
1 … 1RContains 2.16.840.1.113883.10.20.2.5 General Status Section (2013‑01‑31)conf‑9617
cda:component
1 … 1RContains 2.16.840.1.113883.10.20.22.2.20 History of Past Illness Section (2013‑01‑31)conf‑9619
cda:component
0 … 1RContains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2013‑01‑31)conf‑9621
cda:component
1 … 1RContains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (2013‑01‑31)conf‑9623
cda:component
1 … 1RContains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (2013‑01‑31)conf‑9625
cda:component
0 … 1MAY contain zero or one [0..1] Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12)
Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2013‑01‑31)
conf‑9627
cda:component
1 … 1RContains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (2013‑01‑31)conf‑9629
cda:component
1 … 1RContains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2013‑01‑31)conf‑9631
cda:component
1 … 1RContains 2.16.840.1.113883.10.20.22.2.17 Social History Section (2013‑01‑31)conf‑9633
cda:component
1 … 1RContains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (2013‑01‑31)conf‑9635
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (2013‑01‑31)conf‑9987
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (2013‑01‑31)conf‑9988
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (2013‑01‑31)conf‑9989
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (2013‑01‑31)conf‑9990
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.45 Instructions Section (2013‑01‑31)confdots6807