Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

History And Physical Note

[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.3]

A History and Physical  Note is a medical report that documents the current and past conditions of the patient. It contains essential information that helps determine an individual's health status.
The first portion of the report is a current collection of organized information unique to an individual, typically supplied by the patient or their caregiver, about the current medical problem or the reason for the patient encounter. This information is followed by a description of any past or ongoing medical issues, including current medications and allergies. Information is also obtained about the patient's lifestyle, habits, and diseases among family members.
The next portion of the report contains information obtained by physically examining the patient and gathering diagnostic information in the form of laboratory tests, imaging, or other diagnostic procedures.
The report ends with the clinician's assessment of the patient's situation and the intended plan to address those issues.
A History and Physical Examination is required upon hospital admission as well as before operative procedures. An initial evaluation in an ambulatory setting is often documented in the form of an History and Physical Note.

History And Physical Note Header Constraints

History And Physical Note Body Constraints

  1. SHALL contain exactly one [1..1] templateId ( CONF:8283 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.3"
  2. SHALL conform to General Header Constraints template (templateId: 2.16.840.1.113883.10.20.22.1.1) (CONF:9968)
  3. SHALL contain exactly one [1..1] code (CONF:17185), where the @code SHALL be selected from ValueSet HPDocumentType 3. 2.16.840.1.113883.1.11.20.22 DYNAMIC (CONF:17186)
  4. MAY contain zero or more [0..*] inFulfillmentOf (CONF:8336, CONF:8337)
    • An inFulfillmentOf element records the prior orders that are fulfilled (in whole or part) by the service events described in this document. For example, the prior order might be a referral and this HP Note may be in partial fulfillment of that referral.

    1. Contains exactly one [1..1] CDA In Fulfillment Of
  5. SHALL contain exactly one [1..1] componentOf (CONF:8338)
    1. This componentOf SHALL contain zero or one [0..1] encompassingEncounter (CONF:8339)
      1. This encompassingEncounter SHALL contain exactly one [1..1] effectiveTime (ii., CONF:8341)
      2. This encompassingEncounter SHALL contain exactly one [1..1] id (i., CONF:8340)
      3. This encompassingEncounter MAY contain zero or one [0..1] location, where its type is CDA Location (CONF:8344)
        1. Contains exactly one [1..1] CDA Location
      4. This encompassingEncounter MAY contain zero or one [0..1] responsibleParty (iv., CONF:8345)
        1. This responsibleParty SHALL contain exactly one [1..1] assignedEntity, where its type is CDA Assigned Entity (CONF:8348)
          1. Contains exactly one [1..1] CDA Assigned Entity
        2. This responsibleParty The responsibleParty element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both. (CONF:8348)
      5. This encompassingEncounter MAY contain zero or one [0..1] encounterParticipant (v., CONF:8342)
        1. This encounterParticipant SHALL contain exactly one [1..1] assignedEntity, where its type is CDA Assigned Entity (CONF:8343)
          1. Contains exactly one [1..1] CDA Assigned Entity
        2. This encounterParticipant The responsibleParty element, if present, SHALL contain an assignedEntity element which SHALL contain an assignedPerson element, a representedOrganization element, or both. (CONF:8343)
  6. SHALL contain exactly one [1..1] component (CONF:9602)
    1. Contains exactly one [1..1] Allergies Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.6)
  7. MAY contain zero or one [0..1] component (CONF:9605)
    1. Contains exactly one [1..1] Assessment Section (templateId: 2.16.840.1.113883.10.20.22.2.8)
  8. MAY contain zero or one [0..1] component (CONF:9607)
    1. Contains exactly one [1..1] Plan Of Care Section (templateId: 2.16.840.1.113883.10.20.22.2.10)
  9. MAY contain zero or one [0..1] component (CONF:9987)
    1. Contains exactly one [1..1] Assessment And Plan Section (templateId: 2.16.840.1.113883.10.20.22.2.9)
  10. MAY contain zero or one [0..1] component (CONF:9611)
    1. Contains exactly one [1..1] Chief Complaint Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1)
  11. MAY contain zero or one [0..1] component (CONF:9613)
    1. Contains exactly one [1..1] Chief Complaint And Reason For Visit Section (templateId: 2.16.840.1.113883.10.20.22.2.13)
  12. SHALL contain exactly one [1..1] component (CONF:9615)
    1. Contains exactly one [1..1] Family History Section (templateId: 2.16.840.1.113883.10.20.22.2.15)
  13. SHALL contain exactly one [1..1] component (CONF:9617)
    1. Contains exactly one [1..1] General Status Section (templateId: 2.16.840.1.113883.10.20.2.5)
  14. SHALL contain exactly one [1..1] component (CONF:9619)
    1. Contains exactly one [1..1] History Of Past Illness Section (templateId: 2.16.840.1.113883.10.20.22.2.20)
  15. SHALL contain exactly one [1..1] component (CONF:9623)
    1. Contains exactly one [1..1] Medications Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.1)
  16. SHALL contain exactly one [1..1] component (CONF:9625)
    1. Contains exactly one [1..1] Physical Exam Section (templateId: 2.16.840.1.113883.10.20.2.10)
  17. MAY contain zero or one [0..1] component (CONF:9627)
    1. Contains exactly one [1..1] Reason For Visit Section (templateId: 2.16.840.1.113883.10.20.22.2.12)
  18. SHALL contain exactly one [1..1] component (CONF:9629)
    1. Contains exactly one [1..1] Results Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.3)
  19. SHALL contain exactly one [1..1] component (CONF:9631)
    1. Contains exactly one [1..1] Review Of Systems Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.18)
  20. SHALL contain exactly one [1..1] component (CONF:9633)
    1. Contains exactly one [1..1] Social History Section (templateId: 2.16.840.1.113883.10.20.22.2.17)
  21. SHOULD contain zero or one [0..1] component (CONF:9621)
    1. Contains exactly one [1..1] History Of Present Illness Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.4)
  22. MAY contain zero or one [0..1] component (CONF:9637)
    1. Contains exactly one [1..1] Immunizations Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.2)
  23. MAY contain zero or one [0..1] component (CONF:9639)
    1. Contains exactly one [1..1] Problem Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.5)
  24. MAY contain zero or one [0..1] component (CONF:9641)
    1. Contains exactly one [1..1] Procedures Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.7)
  25. SHALL contain exactly one [1..1] component (CONF:9635)
    1. Contains exactly one [1..1] Vital Signs Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.4)
  26. MAY contain zero or one [0..1] component (CONF:16807)
    1. Contains exactly one [1..1] Instructions Section (templateId: 2.16.840.1.113883.10.20.22.2.45)
  27. SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section (CONF:9986)
  28. SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present
  29. SHALL include a Chief Complaint and Reason for Visit Section, Chief Complaint Section, or a Reason for Visit Section (CONF:9642)
  30. SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section. (CONF:10057)

History And Physical Note Example

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  <versionNumber value="1"/>
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    <patientRole/>
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  <author>
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    <time/>
    <assignedAuthor/>
  </author>
  <custodian/>
  <inFulfillmentOf/>
  <componentOf>
    <encompassingEncounter>
      <id root="MDHT" extension="1330889688"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <responsibleParty/>
      <encounterParticipant/>
      <location/>
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  </componentOf>
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              <code code="469700782"/>
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                <low value="2013"/>
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          <entry>
            <encounter>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1230007737"/>
              <code code="1512259758"/>
              <effectiveTime>
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          <entry>
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              <id root="MDHT" extension="88572192"/>
              <code code="534000890"/>
              <effectiveTime>
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          <entry>
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              <id root="MDHT" extension="1017898961"/>
              <code code="326971509"/>
              <effectiveTime value="20130627"/>
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          <entry>
            <supply classCode="SPLY">
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              <id root="MDHT" extension="977754260"/>
              <code code="1828771471"/>
              <effectiveTime value="20130627"/>
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              <subject/>
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              <effectiveTime>
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              <entryRelationship>
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              <entryRelationship>
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              <precondition/>
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              <code code="350320229"/>
              <effectiveTime>
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          <entry>
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              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1216057057"/>
              <code code="773954288"/>
              <effectiveTime>
                <low value="2013"/>
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              <entryRelationship>
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          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="449418596"/>
              <code code="1835587047"/>
              <effectiveTime>
                <low value="2013"/>
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          <entry>
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              <typeId root="2.16.840.1.113883.1.3"/>
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              <effectiveTime>
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              <entryRelationship>
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              <entryRelationship>
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              <entryRelationship>
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              <entryRelationship>
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              <precondition/>
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          <code code="383233422"/>
          <title>TEXT FOR TITLE</title>
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          <entry>
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              <id root="MDHT" extension="1278026676"/>
              <code code="367235672"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <specimen/>
              <performer/>
              <entryRelationship typeCode="COMP" inversionInd="true"/>
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              <entryRelationship>
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              <entryRelationship>
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          <entry>
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