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Template History and Physical (V3) 2015‑08‑01

Id2.16.840.1.113883.10.20.22.1.3Effective Date2015‑08‑01
Statusdraft DraftVersion Label2.1
NameHistoryandPhysicalV3Display NameHistory and Physical (V3)
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. This is typically supplied by the patient or the caregiver, concerning 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 22 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.26Transactionfinal History and Physical (V3)2015‑08‑01
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1Containmentdraft Chief Complaint Section (2.1)2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.4Containmentdraft History of Present Illness Section (2.1)2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.18Containmentdraft Review of Systems Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.2.5Containmentdraft General Status Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.2.10Containmentdraft Physical Exam Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.1Containmentdraft Medications Section (entries optional) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.2Containmentdraft Immunizations Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.3Containmentdraft Results Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.4Containmentdraft Vital Signs Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.5Containmentdraft Problem Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6Containmentdraft Allergies and Intolerances Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.7Containmentdraft Procedures Section (entries optional) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.8Containmentdraft Assessment Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.9Containmentdraft Assessment and Plan Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Treatment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.12Containmentdraft Reason for Visit Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.13Containmentdraft Chief Complaint and Reason for Visit Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.15Containmentdraft Family History Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.17Containmentdraft Social History Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.20Containmentdraft Past Medical History (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.45Containmentdraft Instructions Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.5.3Containmentdraft US Realm Date and Time (DT.US.FIELDED) (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-

Specialization: template 2.16.840.1.113883.10.20.22.1.1 US Realm Header (V3) (2015‑08‑01)
Version: template 2.16.840.1.113883.10.20.22.1.3 History and Physical (2013‑01‑31)
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
RWhen asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 SHALL include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32939).
HistdotsalV3
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.3
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1198-8283) such that itCONFdots8283
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.3CONFdots0046
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.3" (CONF:1198-10046).
@extension
st1 … 1F2015-08-01CONFdots2518
 SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32518).
cda:code
1 … 1SHALL contain exactly one [1..1] code (CONF:1198-17185).

The H&P Note recommends use of a single document type code, 34117-2 "History and physical note”, with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. 		CONFdots7185
cda:informationRecipient
0 … *MAY contain zero or more [0..*] informationRecipient (CONF:1198-32482).CONFdots2482
cda:intendedRecipient
1 … 1The informationRecipient, if present, SHALL contain exactly one [1..1] intendedRecipient (CONF:1198-32483).CONFdots2483
cda:participant
0 … *MAY contain zero or more [0..*] participant (CONF:1198-8286).

The participant element in the H&P header follows the General Header Constraints for participants. H&P Note does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations.		CONFdots8286
 ConstraintWhen 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
cda:inFulfillmentOf
0 … *MAY contain zero or more [0..*] inFulfillmentOf (CONF:1198-8336).

inFulfillmentOf elements describe 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 the H&P Note may be in partial fulfillment of that referral.		CONFdots8336
cda:componentOf
1 … 1MSHALL contain exactly one [1..1] componentOf (CONF:1198-8338).

The H&P Note is always associated with an encounter.		CONFdots8338
cda:encompassingEncounter
1 … 1MContains 2.16.840.1.113883.10.20.22.5.3 US Realm Date and Time (DT.US.FIELDED) (2015‑08‑13)CONFdots8339
cda:id
II1 … *This encompassingEncounter SHALL contain at least one [1..*] id (CONF:1198-8340).CONFdots8340
cda:responsibleParty
0 … 1This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:1198-8345).

The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care.		CONFdots8345
 Schematron assertrolered error 
 testcda:assignedPerson | cda:representedOrganization 
 MessageThe responsibleParty element, if present, *SHALL* contain an assignedEntity element, which *SHALL* contain an assignedPerson element, a representedOrganization element, or both. 
cda:encounterParticipant
0 … *This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:1198-8342).

The encounterParticipant elements represent only those participants in the encounter, not necessarily the entire episode of care. 		CONFdots8342
 Schematron assertrolered error 
 testcda:assignedPerson | cda:representedOrganization 
 MessageAn encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both. 
cda:location
0 … 1This encompassingEncounter MAY contain zero or one [0..1] location (CONF:1198-8344).CONFdots8344
cda:component
1 … 1MSHALL contain exactly one [1..1] component (CONF:1198-8349).CONFdots8349
cda:structuredBody
1 … 1MThis component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30570).

In this template (templateId 2.16.840.1.113883.10.20.22.1.3.2), coded entries are optional.		CONFdots0570
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.6 Allergies and Intolerances Section (entries optional) (V3) (2015‑08‑01)CONFdots0571
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13)CONFdots0573
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09)CONFdots0575
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09)CONFdots0577
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2015‑08‑13)CONFdots0579
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2015‑08‑13)CONFdots0581
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01)CONFdots0583
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.2.5 General Status Section (2015‑08‑13)CONFdots0585
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01)CONFdots0587
cda:component
0 … 1RContains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2015‑08‑13)CONFdots0589
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (V3) (2015‑08‑01)CONFdots0591
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.45 Instructions Section (V2) (2014‑06‑09)CONFdots0593
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (V2) (2014‑06‑09)CONFdots0595
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01)CONFdots0597
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (V3) (2015‑08‑01)CONFdots0599
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (2014‑06‑09)CONFdots0601
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2015‑08‑13)CONFdots0603
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (V3) (2015‑08‑01)CONFdots0605
cda:component
1 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2015‑08‑13)CONFdots0607
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01)CONFdots0609
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (V3) (2015‑08‑01)CONFdots0611
 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' 
 MessageThis structuredBody *SHALL* contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) or a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) 
 Schematron assertrolered error 
 test//cd:templateId[@root='2.16.840.1.113883.10.20.22.2.9' or (//cd:templateId[@root='2.16.840.1.113883.10.20.22.2.8' and //cd:templateId[@root='(2.16.840.1.113883.10.20.22.2.10') 
 MessageThis structuredBody *SHALL* contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09).  
 Schematron assertrolered error 
 testnot(//cd:templateId[@root='2.16.840.1.113883.10.20.22.2.9') or (not(//cd:templateId[@root='2.16.840.1.113883.10.20.22.2.8') and not(//cd:templateId[@root='(2.16.840.1.113883.10.20.22.2.10')) 
 MessageThis structuredBody *SHALL NOT* contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present. 
 Schematron assertrolered error 
 testnot(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13']) or //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'] 
 MessageThis structuredBody *SHALL NOT* contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present