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pending Template  History and Physical

Template 2.16.840.1.113883.10.20.22.1.3 - HistoryandPhysical
Id 2.16.840.1.113883.10.20.22.1.3
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Document Level Template
Context Pathname //
Open/Closed Open (other than defined elements are allowed)
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.
Used by / Uses
Used by / Uses 21 templates
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.2.6 Containment AllergiesSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.8 Containment AssessmentSection DYNAMIC
2.16.840.1.113883.10.20.22.2.10 Containment PlanofCareSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Containment ChiefComplaintSection DYNAMIC
2.16.840.1.113883.10.20.22.2.13 Containment ChiefComplaintandReasonforVisitSection DYNAMIC
2.16.840.1.113883.10.20.22.2.15 Containment FamilyHistorySection DYNAMIC
2.16.840.1.113883.10.20.2.5 Containment GeneralStatusSection DYNAMIC
2.16.840.1.113883.10.20.22.2.20 Containment HistoryofPastIllnessSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.4 Containment HistoryofPresentIllnessSection DYNAMIC
2.16.840.1.113883.10.20.22.2.1 Containment MedicationsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.2.10 Containment PhysicalExamSection DYNAMIC
2.16.840.1.113883.10.20.22.2.12 Containment ReasonforVisitSection DYNAMIC
2.16.840.1.113883.10.20.22.2.3 Containment ResultsSectionentriesoptional DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.18 Containment ReviewofSystemsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.17 Containment SocialHistorySection DYNAMIC
2.16.840.1.113883.10.20.22.2.4 Containment VitalSignsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.9 Containment AssessmentandPlanSection DYNAMIC
2.16.840.1.113883.10.20.22.2.2 Containment ImmunizationsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.5 Containment ProblemSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.7 Containment ProceduresSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.45 Containment InstructionsSection DYNAMIC
Item DT Card Conf Description Label
cda:ClinicalDocument
(HistoryandPhysical)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:8283) such that it conf‑8283
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.1.3
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:17185). conf‑17185
treetree cda:participant
0 .. * MAY contain zero or more [0..*] participant (CONF:8286).

A participant element, if present, SHALL contain an associatedEntity element which SHALL contain either an associatedPerson or scopingOrganization element.

A special class of participant is the supporting person or organization: an individual or an organization that has a relationship to the patient, including parents, relatives, caregivers, insurance policyholders, and guarantors. In the case of a supporting person who is also an emergency contact or next-of-kin, a participant element should be present for each role recorded.

c. When participant/@typeCode is IND, associatedEntity/@classCode SHALL be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30
conf‑8286
  Schematron assert role red error
  test cda:associatedEntity[cda:associatedPerson | cda:scopingOrganization]
  Message A participant element, if present, SHALL contain an associatedEntity element which SHALL contain either an associatedPerson or scopingOrganization element.
treetree cda:inFulfillmentOf
0 .. * MAY contain zero or more [0..*] inFulfillmentOf (CONF:8336).

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 SHALL contain exactly one [1..1] componentOf (CONF:8338). conf‑8338
treeblank treetree cda:encompassingEncounter
1 .. 1 M This componentOf SHALL contain exactly one [1..1] encompassingEncounter (CONF:8339). conf‑8339
treeblank treeblank treetree cda:id
1 .. 1 M This encompassingEncounter SHALL contain exactly one [1..1] id (CONF:8340). conf‑8340
treeblank treeblank treetree cda:effectiveTime
1 .. 1 M This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (CONF:8341).

The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
conf‑8341
  Schematron assert role red error
  test string-length(cda:componentOf/cda:encompassingEncounter/cda:effectiveTime//@value)>=8
  Message The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
treeblank treeblank treetree cda:responsibleParty
0 .. 1 This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (CONF:8345).

The responsibleParty element records only the party responsible for the encounter, not necessarily the entire episode of care.

The responsibleParty element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both.
conf‑8345
  Schematron assert role red error
  test not(cda:componentOf/cda:encompassingEncounter/cda:responsibleParty) or cda:componentOf/cda:encompassingEncounter/cda:responsibleParty/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 .. * This encompassingEncounter MAY contain zero or more [0..*] encounterParticipant (CONF:8342).

An encounterParticipant element, if present, SHALL contain an assignedEntity element, which SHALL contain an assignedPerson element, a representedOrganization element, or both.

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 not(cda:componentOf/cda:encompassingEncounter/cda:encounterParticipant) or cda:componentOf/cda:encompassingEncounter/cda:encounterParticipant/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.
treeblank treeblank treetree cda:location
0 .. 1 This encompassingEncounter MAY contain zero or one [0..1] location (CONF:8344). conf‑8344
treetree cda:component
1 .. 1 M SHALL contain exactly one [1..1] component (CONF:8349).

A History and Physical document can have either a structuredBody or a nonXMLBody.

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

SHALL include a Chief Complaint and Reason for Visit Section, Chief Complaint Section, or a Reason for Visit Section

SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.

SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present

SHALL NOT contain a Chief Complaint and Reason for Visit Section when either a Chief Complaint Section or a Reason for Visit Section is present
conf‑8349
  Schematron assert role red error
  test count(cda:component/cda:structuredBody | cda:component/cda:nonXMLBody)=1
  Message A History and Physical document can have either a structuredBody or a nonXMLBody.
Choice min 1 element(s) and max 1 element(s). Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
treeblank treeblank treetree cda:nonXMLBody
conf‑8349
treeblank treeblank treetree cda:structuredBody
conf‑8349
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.6']]
1 .. 1 M conf‑9602
  Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.8']]
0 .. 1 conf‑9605
  Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.10']]
0 .. 1 conf‑9607
  Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1']]
0 .. 1 conf‑9611
  Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.13']]
0 .. 1 conf‑9613
  Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.15']]
1 .. 1 M conf‑9615
  Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.2.5']]
1 .. 1 M conf‑9617
  Contains 2.16.840.1.113883.10.20.2.5 General Status Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.20']]
1 .. 1 M conf‑9619
  Contains 2.16.840.1.113883.10.20.22.2.20 History of Past Illness Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.4']]
0 .. 1 R conf‑9621
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.1']]
1 .. 1 M conf‑9623
  Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.2.10']]
1 .. 1 M conf‑9625
  Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12']]
MAY contain zero or one [0..1] Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12) conf‑9627
  Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (DYNAMIC)
  Schematron assert role red error
  test count(//cda:section/cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12']) < 2
  Message MAY contain zero or one [0..1] Reason for Visit Section (templateId:2.16.840.1.113883.10.20.22.2.12)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.3']]
1 .. 1 M conf‑9629
  Contains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.18']]
1 .. 1 M conf‑9631
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.17']]
1 .. 1 M conf‑9633
  Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.4']]
1 .. 1 M conf‑9635
  Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (DYNAMIC)
  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='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:templateId[@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:templateId[@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.
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.9']]
0 .. 1 conf‑9987
  Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.2']]
0 .. 1 conf‑9988
  Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.5']]
0 .. 1 conf‑9989
  Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.7']]
0 .. 1 conf‑9990
  Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (DYNAMIC)
  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:templateId[@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:templateId[@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 not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'] and (//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] or //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12']))
  Message SHALL NOT contain a Chief Complaint and Reason for Visit Section when either a Chief Complaint Section or a Reason for Visit Section is present
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.45']]
0 .. 1 conf‑16807
  Contains 2.16.840.1.113883.10.20.22.2.45 Instructions Section (DYNAMIC)