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Template History of Present Illness Section 2014‑07‑29 11:35:31

Id2.16.840.1.113883.3.1937.99.61.5.10.900282Effective Date2014‑07‑29 11:35:31
Statusdraft DraftVersion Label
NameHistoryofPresentIllnessDisplay NameHistory 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.
ContextParent nodes of template element with id 2.16.840.1.113883.3.1937.99.61.5.10.900282
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 2 templates, Uses 0 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.61.5.4.22Transactiondraft CDA Document APSR22014‑11‑16 11:45:10
2.16.840.1.113883.3.1937.99.61.5.10.900273linkdraft Anatomic Pathology Structured Report2014‑05‑13 11:57:57
2.16.840.1.113883.3.1937.99.61.5.10.900275Includedraft APSR2 Clinical Information Section2014‑05‑13 14:38:08
RelationshipSpecialization: template 1.3.6.1.4.1.19376.1.5.3.1.3.4 (2012‑06‑01)
Example
Example
<section classCode="DOCSECT" moodCode="EVN">
  <templateId root="2.16.840.1.113883.2.11.10.103"/>  <code code="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>
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.4"/>  <code codeSystem="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>
ItemDTCardConfDescriptionLabel
hl7:section
0 … *Histdotsness
@classCode
cs0 … 1FDOCSECT
@moodCode
cs0 … 1FEVN
hl7:templateId
II1 … 1RHistdotsness
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.3.4
hl7:templateId
II1 … 1MHistdotsness
@root
uid1 … 1F2.16.840.1.113883.3.1937.99.61.5.10.900282
hl7:code
CD1 … 1MHistdotsness
@code
CONF1 … 1F10164-2
@codeSystem
1 … 1F2.16.840.1.113883.6.1
hl7:title
ST1 … 1MHistdotsness
 Example<title> History of present illness </title>
hl7:text
SD.TEXT1 … 1MHistdotsness
 Example<text>Carcinoma of breast. Post operative diagnosis: same. Left UOQ breast mass. </text>