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draft Template  Medical (General) History Section

Id 2.16.840.1.113883.10.20.22.2.39
ref
ccda-
 		Effective Date 2015‑08‑13
Status draft Draft Version Label 2.1
Name MedicalGeneralHistorySection Display Name Medical (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.
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.39
Classification CDA Section Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 3 templates, Uses 0 templates
Used by as Name Version
1.2.840.10008.9.2 Containment draft Clinical Information (DICOM-20150324) 2021‑06‑22 11:38:24
1.2.840.10008.9.1.10.12 link draft Diagnostic Imaging Report (DICOM-20150324) 2021‑08‑04 07:04:03
2.16.840.1.113883.2.51.10.1.9.1 link cancelled XeH Imaging Report 2021‑06‑22 14:23:06
Relationship Specialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
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ad1bbr-
Item DT Card Conf Description Label
cda:section
 		(Meddotsion)
cda:templateId
 		II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:81-8160) such that it CONFdots8160
@root
 		1 … 1 F 2.16.840.1.113883.10.20.22.2.39 CONFdots0403
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.39" (CONF:81-10403).
cda:code
 		CE 1 … 1 M SHALL contain exactly one [1..1] code (CONF:81-15379). CONFdots5379
@code
 		CONF 1 … 1 F 11329-0
@codeSystem
 		1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
cda:title
 		ST 1 … 1 SHALL contain exactly one [1..1] title (CONF:81-8162). CONFdots8162
cda:text
 		SD.TEXT 1 … 1 R SHALL contain exactly one [1..1] text (CONF:81-8163). CONFdots8163