Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.39 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: MedicalGeneralHistorySection | |||
Other Identifiers: : urn:oid:2.16.840.1.113883.10.20.22.2.39 |
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.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Section
Summary
Mandatory: 7 elements
Slices
This structure defines the following Slices:
This structure is derived from CDAR2.Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | CDAR2.Section | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
code | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: 11329-0 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ED | ||
text | 1..1 | xhtml | ||
Documentation for this format |
This structure is derived from CDAR2.Section
Summary
Mandatory: 7 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Section
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Section | 1..1 | CDAR2.Section | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
code | 1..1 | CE | ||
code | 1..1 | string | Required Pattern: 11329-0 | |
codeSystem | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
title | 1..1 | ED | ||
text | 1..1 | xhtml | ||
Documentation for this format |
Snapshot View
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
Section.nullFlavor | required | NullFlavor |
Section.classCode | required | Fixed Value: DOCSECT |
Section.moodCode | required | Fixed Value: EVN |
Section.templateId:primary.nullFlavor | required | NullFlavor |
Section.code | extensible | DocumentSectionType |
Section.code.nullFlavor | required | NullFlavor |
Section.languageCode | required | HumanLanguage |
Section.subject.typeCode | required | Fixed Value: SBJ |
Section.subject.contextControlCode | required | Fixed Value: OP |
Section.subject.awarenessCode | extensible | TargetAwareness |
Section.informant.typeCode | required | Fixed Value: INF |
Section.informant.contextControlCode | required | Fixed Value: OP |
Id | Grade | Path | Details | Requirements |
only-one-statement | error | Section.entry | SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |