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active Template  History Of Past Illness Section - coded

Id 2.16.756.5.30.1.1.10.3.50
ref
ch-pcc-
Effective Date 2016‑11‑12
Other versions this id:
Status active Active Version Label 2016
Name chpcc_section_HistoryOfPastIllnessCoded Display Name History Of Past Illness Section - coded
Description

Chapter (CDA Body Section) containing the history of past illness according to IHE PCC Technical Framework Revision 11.0 - November 11, 2016.

This section contains the anamnesis of the patient. The section MUST contain at least one Problem entry. In case of no problems, one of the 'special case' codes MUST be used.

In the context of immunizations, only the diseases should be mentioned which lead to a natural immunization.

Context Parent nodes of template element with id 2.16.756.5.30.1.1.10.3.50
Label IHE PCC TF2 Rev.11, 6.3.3.2.5
Classification CDA Section Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 3 transactions and 6 templates, Uses 1 template
Used by as Name Version
cdachvacd-transaction-5 Transaction pending CDA-CH-VACD - Immunization Recommendation Request (2018) 2018‑04‑10 18:08:44
cdachvacd-transaction-6 Transaction pending CDA-CH-VACD - Immunization Recommendation Response (2018) 2018‑04‑10 18:09:59
cdachvacd-transaction-7 Transaction pending CDA-CH-VACD - Vaccination Record (2018) 2018‑04‑10 18:10:49
2.16.756.5.30.1.1.10.1.17 Containment active Immunization Recommendation Request (2020) 2020‑06‑26
2.16.756.5.30.1.1.10.1.17 Containment rejected Immunization Recommendation Request (2018) 2018‑04‑19
2.16.756.5.30.1.1.10.1.18 Containment active Immunization Recommendation Response (2020) 2020‑06‑26
2.16.756.5.30.1.1.10.1.18 Containment rejected Immunization Recommendation Response (2018) 2018‑04‑19
2.16.756.5.30.1.1.10.1.19 Containment active Vaccination Record (2020) 2020‑06‑26
2.16.756.5.30.1.1.10.1.19 Containment rejected Vaccination Record (2018) 2018‑04‑19
Uses as Name Version
2.16.756.5.30.1.1.10.4.90 Containment active Problem Concern Entry (2016) DYNAMIC
Relationship Specialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-

Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.3.8 eHDSI History Of Past Illness (DYNAMIC)
ref
epsos-
Example
Example
<section>
  <templateId root="2.16.756.5.30.1.1.10.3.50"/>  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.3.8"/>  <code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PAST ILLNESS"/>  <title>Antécédents médicaux</title>  <text>
    <!-- Narrative Text -->
  </text>
  <entry typeCode="DRIV">
    <!-- template 2.16.756.5.30.1.1.10.4.90 'Problem Concern Entry' -->
  </entry>
</section>
Item DT Card Conf Description Label
hl7:section

Chapter (CDA Body Section) containing the history of past illness according to IHE PCC Technical Framework Revision 11.0 - November 11, 2016.

This section contains the anamnesis of the patient. The section MUST contain at least one Problem entry. In case of no problems, one of the 'special case' codes MUST be used.

In the context of immunizations, only the diseases should be mentioned which lead to a natural immunization.

IHE PCC TF2 Rev.11, 6.3.3.2.5
hl7:templateId
II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.3.2.5
@root
uid 1 … 1 F 2.16.756.5.30.1.1.10.3.50
hl7:templateId
II 1 … 1 M IHE PCC TF2 Rev.11, 6.3.3.2.5
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.3.8
hl7:id
II 0 … 1 R An ID for this section MAY be filled for traceability. IHE PCC TF2 Rev.11, 6.3.3.2.5
@root
uid 1 … 1 R MUST contain the OID of the system that issued the ID. OIDs of code systems, which are published in the public OID registry for the Swiss health care system (oid.refdata.ch) are REQUIRED. Others are NOT ALLOWED.
@extension
st 0 … 1   Contains the ID itself. The ID MUST be unique within the system that issued the ID.
hl7:code
CE 1 … 1 M IHE PCC TF2 Rev.11, 6.3.3.2.5
@code
st 1 … 1 F 11348-0
@codeSystem
oid 1 … 1 F 2.16.840.1.113883.6.1
@codeSystemName
st 1 … 1 F LOINC
@displayName
st 1 … 1 F HISTORY OF PAST ILLNESS
hl7:title
ST 1 … 1 M IHE PCC TF2 Rev.11, 6.3.3.2.5
  CONF
element content shall be "History of Past Illness"
-or-
element content shall be "Bisherige Krankheiten"
-or-
element content shall be "Antécédents médicaux"
-or-
element content shall be "Storia medica"
  Variable let Name languageCode  
  Value substring(/hl7:ClinicalDocument/hl7:languageCode/@code,1,2)  
  Schematron assert role red error  
  test not($languageCode='en') or (text()='History of Past Illness')  
  Message The English title MUST read 'History of Past Illness'  
  Schematron assert role red error  
  test not($languageCode='de') or (text()='Bisherige Krankheiten')  
  Message The German title must MUST read 'Bisherige Krankheiten'  
  Schematron assert role red error  
  test not($languageCode='fr') or (text()='Antécédents médicaux')  
  Message The French title MUST read 'Antécédents médicaux'  
  Schematron assert role red error  
  test not($languageCode='it') or (text()='Storia medica')  
  Message The Italian title MUST read 'Storia medica'  
hl7:text
SD.TEXT 1 … 1 M The narrative text for this section. IHE PCC TF2 Rev.11, 6.3.3.2.5
hl7:entry
1 … * M The narrative text in the text element of the section MUST be generated automatically from the information in this entry.
Contains 2.16.756.5.30.1.1.10.4.90 Problem Concern Entry (DYNAMIC)
IHE PCC TF2 Rev.11, 6.3.3.2.5
@typeCode
cs 1 … 1 F DRIV