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Past Medical History Section

[Section: templateId 2.16.840.1.113883.10.20.2.9]

This section describes the past medical history for the patient. It may contain information about past procedures or other illnesses that might have a bearing on the patient's current illness. Since past medical history can include past surgical history and other procedures, the Procedure History section may be included under the Past Medical History section or it may stand alone as its own section. By the same token, problems can be recorded in a standalone Problems section or in a nested Problems section. Wherever used, procedures and problems should conform to the CCD template for CDA entries cited in the respective sections.

  1. SHALL contain exactly one [1..1] code/@code="11348-0" HISTORY OF PAST ILLNESS (CodeSystem: 2.16.840.1.113883.6.1 LOINC) (CONF-HP-78)
  2. SHALL contain exactly one [1..1] text
  3. SHOULD satisfy: Contains clinical statements.
    • [OCL]: not self.entry->isEmpty()
Figure 1. Past Medical 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">
  <templateId root="2.16.840.1.113883.10.20.2.9"/>
  <id root="1349262688"/>
  <code code="11348-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PAST ILLNESS"/>
  <title/>
  <text/>
</section>