Template History of Present Illness Section 2014‑07‑29 11:35:31
Id
2.16.840.1.113883.3.1937.99.61.5.10.900282
Effective Date
2014‑07‑29 11:35:31
Status
Draft
Version Label
Name
HistoryofPresentIllness
Display Name
History of Present Illness Section
Description
This section describes the history related to the patient’s past complaints, problems, or diagnoses. It records these details up until, and possibly pertinent to, the patient’s current complaint or reason for seeking medical care.
Context
Parent nodes of template element with id 2.16.840.1.113883.3.1937.99.61.5.10.900282
Classification
CDA Section Level Template
Open/Closed
Open (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 2 templates, Uses 0 templates
<sectionclassCode="DOCSECT"moodCode="EVN"> <templateIdroot="2.16.840.1.113883.2.11.10.103"/><codecode="10164-2"codeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC"displayName="History of Present Illness"/><title>History of present illness</title><text>Carcinoma of breast. Post operative diagnosis: same. Left UOQ breast mass.</text></section>
Example
Original C-CDA example
<section> <templateIdroot="1.3.6.1.4.1.19376.1.5.3.1.3.4"/><codecodeSystem="2.16.840.1.113883.6.1"codeSystemName="LOINC"code="10164-2"displayName="HISTORY OF PRESENT ILLNESS"/><title>HISTORY OF PRESENT ILLNESS</title><text> <paragraph>This patient was only recently discharged for a recurrent GI bleed as described below.</paragraph><paragraph>He presented to the ER today c/o a dark stool yesterday but a normal brown stool today. On exam he was hypotensive in the 80s resolved after .... .... .... </paragraph><paragraph>Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal. H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40.</paragraph><paragraph>He was transfused with 6 units of packed red blood cells with .... .... ....</paragraph><paragraph>GI evaluation 12 September: Colonoscopy showed single red clot in .... .... ....</paragraph></text></section>