Name Medical (General) History Effective Date 2012-07 Version Label DICOM-yyyymmdd Status Active History general describes all aspects of 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 Description current procedure or may be more comprehensive. It may also 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 and Social History. Classification CDA Section Level Relationships Invoked by Section Level template Context Open/Closed Open From Consolidated CDA r1.1 Revision History DICOM-yyyymmdd: Addition of optional entries; C-CDA templateID retained Business Nest Element/ Card Elem/ Data Value Value Subsidiary Name Level Attribute Attr Type Conf Template Conf History section 1..1 SHALL > templateId 1..1 SHALL II >@ @root 1..1 SHALL UID SHALL > id 1..* SHALL II > code 1..1 SHALL CD SHALL (11329-0, LOINC, "History General") Title > title 1..1 SHALL ST Text > text 1..1 ED > 0..1 MAY
Name Medical (General) History Effective Date 2012-07 Version Label DICOM-yyyymmdd Status Active Description History general describes all aspects of 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. It may also 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 and Social History. Classification CDA Section Level Relationships Invoked by Section Level template Context Open/Closed Open Revision History From Consolidated CDA r1.1 DICOM-yyyymmdd: Addition of optional entries; C-CDA templateID retained Business Name Nest Level Element/ Attribute Card Elem/ Attr Conf Data Type Value Conf Value Subsidiary Template History section 1..1 SHALL > templateId 1..1 SHALL II >@ @root 1..1 SHALL UID SHALL > id 1..* SHALL II > code 1..1 SHALL CD SHALL (11329-0, LOINC, "History General") Title > title 1..1 SHALL ST Text > text 1..1 ED > 0..1 MAY
sup155_lb.docx