Package | hl7.fhir.us.ccda |
Type | StructureDefinition |
Id | Id |
FHIR Version | R4 |
Source | http://hl7.org/fhir/us/ccda/https://build.fhir.org/ig/HL7/ccda-on-fhir/StructureDefinition-History-and-Physical.html |
Url | http://hl7.org/fhir/us/ccda/StructureDefinition/History-and-Physical |
Version | 1.2.0 |
Status | active |
Date | 2024-03-12T16:03:19+00:00 |
Name | HistoryAndPhysical |
Title | History and Physical |
Experimental | False |
Realm | us |
Authority | hl7 |
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. 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. |
Type | Composition |
Kind | resource |
No resources found
Note: links and images are rebased to the (stated) source
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
![]() ![]() | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
![]() ![]() ![]() | 1..1 | CodeableConcept | History and Physical Binding: HPDocumentType (required) | |
![]() ![]() ![]() | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
![]() ![]() ![]() ![]() | 1..1 | BackboneElement | Allergies and Intolerances Section | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Allergies, adverse reactions, alerts Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | Family History Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Family History Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | General Status Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | General Status Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10210-3 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | Medications Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | History of medication use Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Past Medical History Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | 1..1 | BackboneElement | Physical Exam Section | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Physical Findings Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29545-1 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(Observation) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | Results Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Relevant diagnostic tests and/or laboratory data Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 30954-2 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core Laboratory Result Observation Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | Review of Systems Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Review of Systems Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10187-3 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | Social History Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Social History Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29762-2 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core Smoking Status Observation Profile) | Smoking status |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | Vital Signs Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Vital Signs Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 8716-3 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | 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. |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | History of Present Illness Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() |