Template 2.16.840.1.113883.10.20.22.1.3 History and Physical

2012‑01‑12

Template 2.16.840.1.113883.10.20.22.1.3 - HistoryandPhysical
Id 2.16.840.1.113883.10.20.22.1.3
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑731
Version valid from 2012‑01‑12 status draft
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, typically supplied by the patient or their caregiver, about 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.
Item DT Card Conf Desc Label
cda:ClinicalDocument
conf-731
treetree cda:templateId
II 1..1 M conf‑9968
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8283
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.3
treetree cda:code
1..1 M conf‑8335
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.20.22 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.1.11.20.22"
treetree cda:inFulfillmentOf
0..* O An inFulfillmentOf element records 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 this H&P Note may be in partial fulfillment of that referral. conf‑8336
treetree cda:componentOf
1..1 M conf‑8338
treeblank treetree cda:encompassingEncounter
1..1 M conf‑8339
treeblank treeblank treetree cda:id
II 1..1 M conf‑8340
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8341
Schematron assert Role red error
Test string-length(@value)>=8 or (string-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))))
Message
The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)
treeblank treeblank treetree cda:location
0..1 O conf‑8344
treeblank treeblank treetree cda:responsibleParty
0..1 O The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care. conf‑8345
Schematron assert Role red error
Test cda:assignedEntity[cda:assignedPerson | cda:representedOrganization]
Message
The responsibleParty element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both.
treeblank treeblank treetree cda:encounterParticipant
0..* O The encounterParticipant element, if present, records only participants in the encounter, not necessarily in the entire episode of care. conf‑8342
Schematron assert Role red error
Test cda:assignedEntity[cda:assignedPerson | cda:representedOrganization]
Message
An encounterParticipant element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both.
treetree cda:component
1..1 M A History and Physical document can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.3), coded entries are optional.
If structuredBody, the component/structuredBody SHALL conform to the section constraints below
conf‑8349
Schematron assert Role red error
Test count(cda:structuredBody | cda:nonXMLBody)=1
Message
A History and Physical document can have either a structuredBody or a nonXMLBody.
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present
Schematron assert Role red 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'
Message
SHALL include a Chief Complaint and Reason for Visit Section, Chief Complaint Section, or a Reason for Visit Section
Schematron assert Role red error
Test count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])<=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=0)
Message
SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section