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| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/1.3.6.1.4.1.19376.1.5.3.1.3.4 | Version: 2.1.0-draft1 | |||
| Active as of 2023-01-16 | Computable Name: HistoryofPresentIllnessSection | |||
| Other Identifiers: id: urn:oid:1.3.6.1.4.1.19376.1.5.3.1.3.4 | ||||
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.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Section
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() | 1..1 | CDAR2.Section | Base for all types and resources | |
![]() ![]() | 0..* | II | Slice: Unordered, Open by value:root | |
![]() ![]() ![]() | 1..1 | II | ||
![]() ![]() ![]() ![]() | 1..1 | string | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.3.4 | |
![]() ![]() | 1..1 | CE | ||
![]() ![]() ![]() | 1..1 | string | Required Pattern: 10164-2 | |
![]() ![]() ![]() | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() | 1..1 | ED | ||
![]() ![]() | 1..1 | xhtml | ||
Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() | 1..1 | CDAR2.Section | Base for all types and resources | |
![]() ![]() | 1..1 | code | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
![]() ![]() | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
![]() ![]() | 0..* | II | Slice: Unordered, Open by value:root | |
![]() ![]() ![]() | 1..1 | II | ||
![]() ![]() ![]() ![]() | 1..1 | string | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.3.4 | |
![]() ![]() | 1..1 | CE | Binding: DocumentSectionType (extensible) | |
![]() ![]() ![]() | 1..1 | string | Required Pattern: 10164-2 | |
![]() ![]() ![]() | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() | 1..1 | ED | ||
![]() ![]() | S | 1..1 | xhtml | |
Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Section.classCode | required | Fixed Value: DOCSECT |
| Section.moodCode | required | Fixed Value: EVN |
| Section.code | extensible | DocumentSectionType |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
| 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 (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| 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(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| 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 |
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![]() |
|---|---|---|---|---|
![]() | 1..1 | CDAR2.Section | Base for all types and resources | |
![]() ![]() | 0..* | II | Slice: Unordered, Open by value:root | |
![]() ![]() ![]() | 1..1 | II | ||
![]() ![]() ![]() ![]() | 1..1 | string | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.3.4 | |
![]() ![]() | 1..1 | CE | ||
![]() ![]() ![]() | 1..1 | string | Required Pattern: 10164-2 | |
![]() ![]() ![]() | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() | 1..1 | ED | ||
![]() ![]() | 1..1 | xhtml | ||
Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() | 1..1 | CDAR2.Section | Base for all types and resources | |
![]() ![]() | 1..1 | code | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
![]() ![]() | 1..1 | code | Binding: ActMood (required) Fixed Value: EVN | |
![]() ![]() | 0..* | II | Slice: Unordered, Open by value:root | |
![]() ![]() ![]() | 1..1 | II | ||
![]() ![]() ![]() ![]() | 1..1 | string | Required Pattern: 1.3.6.1.4.1.19376.1.5.3.1.3.4 | |
![]() ![]() | 1..1 | CE | Binding: DocumentSectionType (extensible) | |
![]() ![]() ![]() | 1..1 | string | Required Pattern: 10164-2 | |
![]() ![]() ![]() | 1..1 | string | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() | 1..1 | ED | ||
![]() ![]() | S | 1..1 | xhtml | |
Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Section.classCode | required | Fixed Value: DOCSECT |
| Section.moodCode | required | Fixed Value: EVN |
| Section.code | extensible | DocumentSectionType |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Snapshot View
| 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 (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| 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(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| 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 |
This structure is derived from CDAR2.Section
Summary
Mandatory: 7 elements
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron