Id1.3.6.1.4.1.19376.1.5.3.1.3.4
ref
ccda-
Effective Date2015‑08‑13
Statusdraft DraftVersion Label2.1
NameHistoryofPresentIllnessSectionDisplay NameHistory of Present Illness Section
Description
The History of Present Illness section describes the history related to the reason for the encounter. It contains the historical details leading up to and pertaining to the patient’s current complaint or reason for seeking medical care.
ContextParent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.3.4
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 12 transactions and 6 templates, Uses 0 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.28Transactionfinal Procedure Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.43Transactionfinal Procedure Note (V3) – USCDI2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transactionfinal History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.41Transactionfinal History and Physical (V3) – USCDI2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.25Transactionfinal Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.40Transactionfinal Discharge Summary (V3) – USCDI2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal Consultation Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.37Transactionfinal Consultation Note (V3) – USCDI2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.30Transactionfinal Referral Note (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.45Transactionfinal Referral Note (V2) – USCDI2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.31Transactionfinal Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.46Transactionfinal Transfer Summary (V2) – USCDI2015‑08‑01
2.16.840.1.113883.10.20.22.1.3Containmentdraft History and Physical (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.4Containmentdraft Consultation Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.6Containmentdraft Procedure Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.8Containmentdraft Discharge Summary (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.13Containmentdraft Transfer Summary (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.14Containmentdraft Referral Note (V2) (2.1)2015‑08‑01
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
ItemDTCardConfDescriptionLabel
cda:section
Histdotstion
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:81-7848) such that itCONFdots7848
@root
uid1 … 1F1.3.6.1.4.1.19376.1.5.3.1.3.4CONFdots0458
 SHALL contain exactly one [1..1] @root="1.3.6.1.4.1.19376.1.5.3.1.3.4" (CONF:81-10458).
cda:code
CE1 … 1MSHALL contain exactly one [1..1] code (CONF:81-15477).CONFdots5477
@code
CONF1 … 1F10164-2
@codeSystem
1 … 1F2.16.840.1.113883.6.1
cda:title
ST1 … 1SHALL contain exactly one [1..1] title (CONF:81-7850).CONFdots7850
cda:text
SD.TEXT1 … 1RSHALL contain exactly one [1..1] text (CONF:81-7851).CONFdots7851