StructureDefinition-History-and-Physical

Sourcehl7.fhir.us.ccda#current:C-CDA on FHIR (v4.0.1)
resourceTypeStructureDefinition
idHistory-and-Physical
canonicalhttp://hl7.org/fhir/us/ccda/StructureDefinition/History-and-Physical
version1.2.0-ballot
statusactive
publisherHL7 Structured Documents Working Group
nameHistoryAndPhysical
titleHistory and Physical
date2023-03-27T20:25:00+00:00
descriptionA 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. This is typically supplied by the patient or the caregiver, concerning 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.
jurisdictionsus
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeComposition
derivationconstraint
basehttp://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header
Usages(none)
Name Flags Card. Type Description & Constraints doco
. . Composition USRealmHeader
. . . type History and Physical
Binding: HPDocumentType ( required )
. . . Slices for section Slice: Unordered, Open by value:code
. . . . section:allergies_and_intolerances_section 1..1 Allergies and Intolerances Section
. . . . . title S 1.. title
. . . . . code S 1.. Allergies, adverse reactions, alerts
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:allergies_and_intolerances_entry S Reference (US Core AllergyIntolerance Profile)
. . . . section:family_history_section S 1..1 Family History Section
. . . . . title S 1.. title
. . . . . code S 1.. Family History
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10157-6
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:family_history_section_entry S Reference (US Core AllergyIntolerance Profile)
. . . . section:general_status_section S 1..1 General Status Section
. . . . . title S 1.. title
. . . . . code S 1.. General Status
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10210-3
. . . . . text S 1.. This section contains only human readable content
. . . . section:medications_section S 1..1 Medications Section
. . . . . title S 1.. title
. . . . . code S 1.. History of medication use
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:medications_section_entry S Reference ( MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)
. . . . section:past_medical_history_section S ..1 Past Medical History Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:past_medical_history_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:physical_exam_section 1..1 Physical Exam Section
. . . . . title S 1.. title
. . . . . code S 1.. Physical Findings
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:physical_exam_entry S Reference ( Observation ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:results_section S 1..1 Results Section
. . . . . title S 1.. title
. . . . . code S 1.. Relevant diagnostic tests and/or laboratory data
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 30954-2
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:results_entry S Reference (US Core Laboratory Result Observation Profile)
. . . . section:review_of_systems_section S 1..1 Review of Systems Section
. . . . . title S 1.. title
. . . . . code S 1.. Review of Systems
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
. . . . . text S 1.. This section contains only human readable content
. . . . section:social_history_section S 1..1 Social History Section
. . . . . title S 1.. title
. . . . . code S 1.. Social History
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29762-2
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:smoking_status_entry S Reference (US Core Smoking Status Observation Profile) Smoking status
. . . . section:vital_signs_section S 1..1 Vital Signs Section
. . . . . title S 1.. title
. . . . . code S 1.. Vital Signs
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 8716-3
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:vital_signs_entry S Reference ( Vital Signs Profile ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:history_of_present_illness_section S ..1 History of Present Illness Section
. . . . . title S 1.. title
. . . . . code S 1.. History of Present Illness
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
. . . . . text S 1.. This section contains only human readable content
. . . . section:assessment_and_plan_section S ..1 Assessment and Plan Section. This section represents the clinician’s conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
. . . . . title S 1.. title
. . . . . code S 1.. Assessment and Plan
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51847-2
. . . . . text S 1.. text
. . . . . Slices for entry Slice: Unordered, Open by profile:resolve()
. . . . . . entry:assessment_and_plan_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition | Observation | Communication ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:assessment_section S ..1 Assessment Section
. . . . . title S 1.. title
. . . . . code S 1.. Assessments
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51848-0
. . . . . text S 1.. This section contains only human readable content
. . . . section:chief_complaint_and_reason_for_visit_section S ..1 Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
. . . . . title S 1.. title
. . . . . code S 1.. Chief Complaint and Reason for Visit
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46239-0
. . . . . text S 1.. This section contains only human readable content
. . . . section:chief_complaint_section S ..1 Chief Complaint Section
. . . . . title S 1.. title
. . . . . code S 1.. Chief Complaint
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
. . . . . text S 1.. This section contains only human readable content
. . . . section:immunizations_section S ..1 Immunizations Section
. . . . . title S 1.. title
. . . . . code S 1.. Immunizations
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11369-6
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:immunizations_entry Reference (US Core Immunization Profile)
. . . . section:plan_of_treatment_section S ..1 Plan of Treatment Section
. . . . . title S 1.. title
. . . . . code S 1.. Plan of Treatment
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference (US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:problem_section S ..1 Problem Section
. . . . . title S 1.. title
. . . . . code S 1.. Problem List
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11450-4
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:problem_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:procedures_section S ..1 Procedures Section
. . . . . title S 1.. title
. . . . . code S 1.. History of Procedures
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:procedures_entry S Reference (US Core Procedure Profile)
. . . . section:reason_for_visit_section S ..1 Reason for Visit Section
. . . . . title S 1.. title
. . . . . code S 1.. Reason for Visit
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29299-5
. . . . . text S 1.. This section contains only human readable content
. . . . section:instructions_section S ..1 Instructions Section
. . . . . title S 1.. title
. . . . . code S 1.. Instructions
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 69730-0
. . . . . text S 1.. This section contains only human readable content

doco Documentation for this format

Produced 06 Apr 2023