Back To Index  <<  Back To Templates

pending Template  Medical (General) History Section

Template 2.16.840.1.113883.10.20.22.2.39 - MedicalGeneralHistorySection
Id 2.16.840.1.113883.10.20.22.2.39
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Section Level Template
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.2.39
Open/Closed Open (other than defined elements are allowed)
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.
Used by / Uses
Used by / Uses 1 template
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.1.6 Containment ProcedureNote Procedure Note 2013‑01‑31
Item DT Card Conf Description Label
cda:section
(MedicalGeneralHistorySection)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:8160) such that it conf‑8160
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.2.39
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:15379). conf‑15379
treeblank treetree @code
1 .. 1 F 11329-0
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
treetree cda:title
1 .. 1 M SHALL contain exactly one [1..1] title (CONF:8162). conf‑8162
treetree cda:text
1 .. 1 M SHALL contain exactly one [1..1] text (CONF:8163). conf‑8163