DICOM PS3.20 2019b - Imaging Reports using HL7 Clinical Document Architecture

9.8.3 Medical (General) History

Template ID

2.16.840.1.113883.​10.20.22.2.39

Name

Medical (General) History

Effective Date

2012-07

Version Label

DICOM-20150324

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

Included in 9.2 Clinical Information

Context

parent node

Open/Closed

Open

Revision History

From Consolidated CDA r1.1

DICOM-20150324: 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

>

template​Id

1..1

SHALL

II

>@

@root

1..1

SHALL

UID

SHALL

2.16.840.1.113883.​10.20.22.2.39

>

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

COND

ED

9.1.1 Section Text 1.2.840.10008.9.19

>

0..1

MAY

9.1.2 General Section Entries 1.2.840.10008.9.23

9.8.3.1 section/text

In the context of an Imaging Report, the section/text should document any contraindications to contrast administration or other procedure techniques that affected the selection or performance of the protocol.

Example 9.8.3.1-1. Medical (General) History section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.20.22.2.39"/>
    <id root="1.2.840.10213.2.62.7044785528.114289875"/>
    <code code="11329-0"
        codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC"
        displayName="History General"/>
    <title>Relevant Medical History</title>
    <text>
        <list>
            <item>Patient reported adverse reaction to iodine.</item>
            <item>Patient is smoker (1 pack daily).</item>
        </list>
    </text>
</section>

DICOM PS3.20 2019b - Imaging Reports using HL7 Clinical Document Architecture