Id	2.16.840.1.113883.10.20.22.1.3	Effective Date	2016‑12‑20 15:02:58
Status	Active	Version Label	MU2
Name	MU2HistoryandPhysical	Display Name	MU2 H&P Note
Context	Pathname **
Label	MU2‑057
Classification	CDA Document Level Template
Open/Closed	Open (other than defined elements are allowed)
Used by / Uses	Used by 0 transactions and 0 templates, Uses 24 templates Uses as Name Version 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Containment Chief Complaint Section (1.1) 2013‑01‑31 1.3.6.1.4.1.19376.1.5.3.1.3.1 Containment Reason for Referral Section (1.1) 2013‑01‑31 1.3.6.1.4.1.19376.1.5.3.1.3.4 Containment History of Present Illness Section (1.1) 2013‑01‑31 1.3.6.1.4.1.19376.1.5.3.1.3.18 Containment Review of Systems Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.2.5 Containment General Status Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.2.10 Containment Physical Exam Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.1 Containment Medications Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.2 Containment Immunizations Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.3 Containment Results Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.4 Containment Vital Signs Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.5 Containment Problem Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.6 Containment Allergies Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.7 Containment Procedures Section (entries optional) (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.8 Containment Assessment Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.9 Containment Assessment and Plan Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.10 Containment Plan of Care Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.12 Containment Reason for Visit Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.13 Containment Chief Complaint and Reason for Visit Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.14 Containment Functional Status Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.15 Containment Family History Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.17 Containment MU2 Social History Section (MU2) DYNAMIC 2.16.840.1.113883.10.20.22.2.20 Containment History of Past Illness Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.41 Containment Hospital Discharge Instructions Section (1.1) 2013‑01‑31 2.16.840.1.113883.10.20.22.2.45 Containment Instructions Section (1.1) 2013‑01‑31
Expand AllCollapse All Item DT Card Conf Description Label cda:ClinicalDocument MU2‑057 cda:templateId II 1 … 1 M MU2‑057 @root uid 1 … 1 F 2.16.840.1.113883.10.20.22.1.3 cda:component 1 … 1 M MU2‑057 cda:structuredBody 1 … 1 MU2‑057 cda:component 1 … 1 M Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (2013‑01‑31) MU2‑057 cda:component 0 … 1 Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2013‑01‑31) MU2‑057 Choice 1 … * Elements to choose from: cda:component containing template 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31) cda:component containing template 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (2013‑01‑31) cda:component 0 … 1 Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31) MU2‑049 cda:component 0 … 1 Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (2013‑01‑31) MU2‑049 Choice 1 … * Elements to choose from: cda:component containing template 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2013‑01‑31) cda:component containing template 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2013‑01‑31) cda:component containing template 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2013‑01‑31) cda:component 0 … 1 Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2013‑01‑31) MU2‑048 cda:component 0 … 1 Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2013‑01‑31) MU2‑048 cda:component 0 … 1 Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2013‑01‑31) MU2‑048 cda:component 0 … 1 R Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (2013‑01‑31) MU2‑038 cda:component 0 … 1 R Contains 2.16.840.1.113883.10.20.2.5 General Status Section (2013‑01‑31) MU2‑038 cda:component 0 … 1 R Contains 2.16.840.1.113883.10.20.22.2.20 History of Past Illness Section (2013‑01‑31) MU2‑038 cda:component 0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2013‑01‑31) MU2‑057 cda:component 1 … 1 M Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (2013‑01‑31) MU2‑057 cda:component 0 … 1 R Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (2013‑01‑31) MU2‑038 cda:component 1 … 1 M Contains 2.16.840.1.113883.10.20.22.2.3 Results Section (entries optional) (2013‑01‑31) MU2‑057 cda:component 0 … 1 R Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2013‑01‑31) MU2‑038 cda:component 1 … 1 M Contains 2.16.840.1.113883.10.20.22.2.17 MU2 Social History Section (DYNAMIC) MU2‑057 cda:component 1 … 1 M Contains 2.16.840.1.113883.10.20.22.2.4 Vital Signs Section (entries optional) (2013‑01‑31) MU2‑057 cda:component 1 … 1 M Contains 2.16.840.1.113883.10.20.22.2.2 Immunizations Section (entries optional) (2013‑01‑31) MU2‑057 cda:component 1 … 1 M Contains 2.16.840.1.113883.10.20.22.2.5 Problem Section (entries optional) (2013‑01‑31) MU2‑057 cda:component 1 … 1 M Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (2013‑01‑31) MU2‑057 cda:component 1 … 1 M Contains 2.16.840.1.113883.10.20.22.2.45 Instructions Section (2013‑01‑31) MU2‑057 cda:component 1 … 1 M Contains 2.16.840.1.113883.10.20.22.2.14 Functional Status Section (2013‑01‑31) MU2‑037 cda:component 1 … 1 M Contains 1.3.6.1.4.1.19376.1.5.3.1.3.1 Reason for Referral Section (2013‑01‑31) MU2‑037 cda:component 1 … 1 M Contains 2.16.840.1.113883.10.20.22.2.41 Hospital Discharge Instructions Section (2013‑01‑31) MU2‑037   Schematron assert role  error     test every $section in //hl7:section[hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.6' or hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.1' or hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.2' or hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.5' or hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.7' or hl7:templateId/@root='2.16.840.1.113883.10.20.22.2.3'] satisfies $section/hl7:entry     Message Entries in Consultation Note are required by MU2 for Allergies, Medications, Immunizations, Problems, Procedures, Laboratory Tests, and Values/Results of Laboratory Tests, in Consultation Note (paragraph 4.2.4, MU2-039)