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Family History Section

[Section: templateId 2.16.840.1.113883.10.20.1.4]

This section contains data defining the patient's genetic relatives in terms of possible or relevant health risk factors that have a potential impact on the patient's healthcare risk profile.

  1. SHALL contain exactly one [1..1] templateId ( ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.1.4"
  2. SHALL contain exactly one [1..1] code/@code="10157-6" History of family member diseases (CodeSystem: 2.16.840.1.113883.6.1 LOINC) (CONF-185, CONF-186)
  3. SHALL contain exactly one [1..1] title (CONF-187)
  4. SHALL contain exactly one [1..1] text
  5. MAY contain at least one [1..*] entry
    1. Contains exactly one [1..1] Family History Organizer (templateId: 2.16.840.1.113883.10.20.1.23)
  6. SHOULD satisfy: Contains a case-insensitive language-insensitive text string containing 'family history'. (CONF-188)
  7. Family History Section SHOULD include one or more family history observations (templateId 2.16.840.1.113883.10.20.1.22), which MAY be contained within family history organizers (templateId 2.16.840.1.113883.10.20.1.23) (CONF-184)
  8. The family history section SHALL NOT contain Section / subject. (CONF-189)

Family History Section example

<?xml version="1.0" encoding="UTF-8"?>
<section xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
  <id root="MDHT" extension="1515549482"/>
  <title>TEXT FOR TITLE</title>
  <text/>
  <entry>
    <organizer>
      <id root="MDHT" extension="1819666878"/>
      <statusCode code="completed"/>
      <effectiveTime>
        <low value="2012"/>
        <high value="2012"/>
      </effectiveTime>
      <component>
        <observation>
          <id root="MDHT" extension="208761616"/>
          <code code="875044886"/>
          <text>Text Value</text>
          <effectiveTime>
            <low value="2012"/>
            <high value="2012"/>
          </effectiveTime>
          <entryRelationship>
            <observation/>
          </entryRelationship>
          <entryRelationship>
            <observation/>
          </entryRelationship>
        </observation>
      </component>
    </organizer>
  </entry>
</section>