Publication Build: This will be filled in by the publication tooling
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/MedicalGeneralHistorySection | Version: 3.0.0 | |||
| Draft as of 2024-05-18 | Computable Name: MedicalGeneralHistorySection | |||
| Other Identifiers: 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 Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
![]() ![]() |
1..* | II | Slice: Unordered, Open by value:root | |
![]() ![]() ![]() |
1..1 | II | ||
![]() ![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
![]() ![]() ![]() ![]() |
0..0 | |||
![]() ![]() |
1..1 | CE | Medical (General) History | |
![]() ![]() ![]() |
1..1 | cs | Required Pattern: 11329-0 | |
![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() |
1..1 | ST | ||
![]() ![]() |
1..1 | xhtml | ||
Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
![]() ![]() |
1..* | II | Slice: Unordered, Open by value:root | |
![]() ![]() ![]() |
1..1 | II | ||
![]() ![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
![]() ![]() |
1..1 | CE | Medical (General) History Binding: DocumentSectionType (example) | |
![]() ![]() ![]() |
1..1 | cs | Required Pattern: 11329-0 | |
![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() |
1..1 | ST | ||
![]() ![]() |
1..1 | xhtml | ||
Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType |
| Path | Conformance | ValueSet / Code | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Differential View
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
![]() ![]() |
1..* | II | Slice: Unordered, Open by value:root | |
![]() ![]() ![]() |
1..1 | II | ||
![]() ![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
![]() ![]() ![]() ![]() |
0..0 | |||
![]() ![]() |
1..1 | CE | Medical (General) History | |
![]() ![]() ![]() |
1..1 | cs | Required Pattern: 11329-0 | |
![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() |
1..1 | ST | ||
![]() ![]() |
1..1 | xhtml | ||
Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
![]() ![]() |
1..* | II | Slice: Unordered, Open by value:root | |
![]() ![]() ![]() |
1..1 | II | ||
![]() ![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.39 | |
![]() ![]() |
1..1 | CE | Medical (General) History Binding: DocumentSectionType (example) | |
![]() ![]() ![]() |
1..1 | cs | Required Pattern: 11329-0 | |
![]() ![]() ![]() |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() |
1..1 | ST | ||
![]() ![]() |
1..1 | xhtml | ||
Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType |
Snapshot View
| Path | Conformance | ValueSet / Code | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |