Id2.16.840.1.113883.10.20.22.2.39
ref
ccda-
Effective Date2015‑08‑13
Statusdraft DraftVersion Label2.1
NameMedicalGeneralHistorySectionDisplay NameMedical (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.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.2.39
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 3 templates, Uses 0 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.28Transactionfinal Procedure Note (V3)2015‑08‑01
1.2.840.10008.9.2Containmentdraft Clinical Information (DICOM-20150324)2021‑06‑22 11:38:24
2.16.840.1.113883.2.51.10.61Containmentactive XeH Clinical Information (DICOM-20150324)2022‑03‑17 11:51:55
2.16.840.1.113883.10.20.22.1.6Containmentdraft Procedure Note (V3) (2.1)2015‑08‑01
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
cda:section
Medidotstion
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:81-8160) such that itCONFdots8160
@root
uid1 … 1F2.16.840.1.113883.10.20.22.2.39CONFdots0403
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.39" (CONF:81-10403).
cda:code
CE1 … 1MSHALL contain exactly one [1..1] code (CONF:81-15379).CONFdots5379
@code
CONF1 … 1F11329-0
@codeSystem
1 … 1F2.16.840.1.113883.6.1
cda:title
ST1 … 1SHALL contain exactly one [1..1] title (CONF:81-8162).CONFdots8162
cda:text
SD.TEXT1 … 1RSHALL contain exactly one [1..1] text (CONF:81-8163).CONFdots8163